Nava! Junior Reserve Officer Training Corps"Raider Battalion"

Required PaperworkPlease sign the required papers and turn them in as soon as possible. Physicals and Health RiskScreening Questionnaire can take a little longer as it takes time to schedule an appointment. lfallyou are waiting on is medical signatures, then please do not wait turning in the rest of theforms.

1. Codet Doto Sheet - Please fill out. lnformation about cadet and point of contact of nextof kin.

2. Weoring of the Novy JROTC Uniform (Regulotions/ - Cadet and Parent's Signatures.

3. Novy JROTC Lab Fees - Parent's Signature.

4. WCSD Navy IROTC Activity Permit - Cadet and Parent's Signatures.

5. NIROTC Stondord Releose Form - Fill out and Parent's Signature required - Gives ReedNJROTC permission to take cadet onto a military facility and gives medical personnelpermission to treat cadet if needed,

6. Dance/Porty Rules ond Regulotions - Cadet's Signature. Due to the current COVID-L9situation, dances and parties are on hold, but go ahead and sign this form ifcircumstances allow us to resume in these types of events later in the school year.

7. Reed High SchoolWeb Page Releose Form - Cadet and Parent's Signature.

8. Areo 73 Health Risk Screening Questionnaire - Answer the questions. Cadet andParent's Signatures required, Medical Practitioner if needed (only if you checked yes toany question on pages 1 and 2 of this form).

9. Letter to Heolth Proctitioner/Physicolform - lnformation for Medical Practitioner onhow to fill out the physical form. Requires Medical Practitioner's signature.

NAVAL JUNlOR RESERVE OFFICERS TRA!N!NG CORPSEdward C. Reed Hight School, 1350 Baring Blvd, Sparks, NV 89434

Cadet Data Sheet

Name:(Last) (First)

Date of Birth: Age: _

Height: inches Weight: pounds

Gender: Race:

(M.t.)

Naval Science Year: 1 / Z / l/+ (circle one)

Present School Grade: 9 / L0 / IL / 12 (circle one)

Parent or Legal Guardian:(Last) (First) (M.t.)

Relation to You:(i.e. mother, father, etc.)

Parent/Guardian Title: Mr. /Mrs. /

Your Home Address:

Do you live with the person listed: Y / N

(Street Address)

(city)

Home Phone #: (_)

Cell Phone #: (_)

(State) (Zip Code)

Work Phone #: (_)

To be contacted in case of emergency - only if parent or guardian is not available

Name:( Last)

Relation to You:

( Fi rst)

(i.e. uncle, aunt, grandparent, etc.)

Home Phone #: (_)

(M.t.)

Cell Phone #: (_)

Work Phone #: (_)

NAVAL JUNIOR RESERVE OFFICERS TRAINING CORPS..RAIDER BATTALION''

Edward C. Reed High School1350 Baring Blvd

Sparks, NV 89434

Senior Naval Science Instructor Naval Science Instructor Naval Science InstructorLCDR S. Myers, USN (Ret.) CMDCM J. Walker, USN (Ret.) YNC P. Prell, USN (Ret.)

August 7,2020

From: Naval Science Instructors, Edward C. Reed High SchoolTo: Cadets and Parents/Guardians of Naval Science Cadets

SUBJ: WEARING OF THE NJROTC UNIFORM

l. The Naval Science classes are required by the Naval Education and Training Command(NETC) to wear the issued uniform once each week. However. we will from time to time wearour uniforms on other occasions such as drill competitions, parades, pass-in-review, awardsceremonies, field trips, etc. as authorized by the Naval Science Instructors and NETC. Certainmodifications may be authorized for drill teams, color guards, and performing units.

2. Cadets will wear their uniforms properly in accordance with the U.S. Navy and NJROTCregulations. Complete uniforms to include shoes will be issued to the cadet by the NJROTCunit. All cadets must wear a clean crew neck white undershirt and plain black socks when in theNJROTC uniform. In addition, all cadets will adhere to Navy cadet grooming standards.

3. While we follow Washoe County School District and Edward C. Reed's policy on the wearingof face masks when not in uniform, the following standard is applied when wearing any Navyuniform on/off campus:

a. Be conservative in appearance, non-offensive and will not bring discredit upon the weareror the Navy.

b. Be of a plain neutral color (black, brown, tan, white, grey, green, blue). No logos, prints,pattems, or lettering/wording are authorized.

c. Fastening devices for masks must be neutral in color and made of elastic, cord or string andloop or tie around the back of the ears or back of the head.

4. Cadets in uniform may not participate during or in connection with political activities, privateemployment, or commercial interest, or at any activity when wearing the uniform may bringdiscredit to the Washoe County School District, Edward. C. Reed High School, NJROTC, or rheUnited States Navy.

5. If in doubt or have questions about the wearing of the Navy uniform, please address to any ofthe NJROTC instructors.

ffil rx-Steven MyersSenior Naval Science Instructor

Cadet Understanding: I understand that, once I receive my NJROTC uniform. I will be heldresponsible for properly wearing the appropriate uniform at least one day each week. I willfurther wear my uniform with pride, I will wear it properly and appropriately anytime I am inpublic or as directed for special occasions by the Naval Science Instructors. I also agree that theNJROTC uniform must be maintained as well as retumed when leaving the NJROTC program.

Cadet's Name (Print) Cadet's Signature Date

ParenUGuardian's Name (Print) Parent/Guardian' s S ignature Date

NAVAL JUNIOR RESERVE OFFICERS TRAINING CORPSEdward C. Reed Hight School, 1350 Baring Blvd, Sparks, NV 89434

NJROTC LAB FEES

Lab fees defer costs of organizational clothing. The fee is 520.00 for First Year Cadets andSfO.OO for returning cadets.

Payment is made to the Edward C. Reed High School Bookkeeper located just inside theschool's main entrance.

Parent/Guardian's Name (Print) Parent/Guardian's Signature

Date

Washoe County School District

Naval Junior Reserve Officers TraininF Corps Activities Permit

Agreement to Obey lnstructions, Release, Assumption of Risk, and Agreementto Hold Harmless in Naval Junior Reserve Officers Training Corps Activities

lnstructions to Student and Parent/Guardian:

Please read both the STUDENT and PARENT (front and back) provisions of this form.Sign, date, and return this form to one of the Naval Science lnstructors.

STUDENT:

I am aware that participating in many of the extra-curricular activities of the Navy JuniorReserve Officers Training Corps (NJROTC) program such as Drill Meets, Field Meets, LeadershipCamps, Mini-Boot Camp, Orienteering Meets, Sailing, Water Safety, etc., and training for theseevents can involve strenuous activities and be dangerous involving MANY RISKS OF INJURY. Iunderstand thatthe dangers and risks of participating in NIROTC activities include, but are notlimited to, death, serious neck and spinal injuries which may result in complete or partialparalysis, brain damage, serious injury to virtually all bones, joints, ligaments, muscles, tendons,and otheraspectsof the muscularskeletal system, and serious injury, but in a seriousimpairment of my future abilities to earn a living, to engage in other business, social andrecreational activities, and generally to enjoy life.

Because of the dangers of participating In a NJROTC extra-curricular activity, I recognize theimportance of following Naval Science lnstructors (NSl) instructions regarding techniques,training and other team rules, etc., and agree to obey such instructions.

ln consideration of the Washoe County School District permitting meto participate in theNJROTC extra-curricular activity and to engage in all activities related to said program, I herebyassume all risks associated with participation and agree to indemnify, defend, and hold theWashoe County School District, its Trustees, employees, agents, representatives, coaches andvolunteers harmless from any and all liability, actions, cause of action, debt, claims or demandsof any kind and nature whatsoever which may arise or in connection with my participation in anoff-season sport/conditioning program.

I fully understand that participation in the NJROTC program does not guarantee me a grade inclass or a position on any of their specialty teams.

The NavyJunior Reserve OfficersTraining Corps hereof shall serve as a release and assumptionof riskfor me, my heirs, estate, executor, administrator, assignees, and for all members of myfamily.

Signature of Student Date

PARENT:

laffirm that lam the parent/guardian of the previously mentioned student. lhave read thestudent warning and release and understand its terms. I understand that all NROTC extra-curricular activities can involve RISK OF INJURY, those risks outlined in the student section

ln consideration of the Washoe County School District permitting my child to participate in anyand all NJROTC extra-curricular activities and program, I hereby agree to indemnify, defend,and hold Washoe County School District, its Trustees, its employees, agents, representatives,Naval Science/NJROTC lnstructors and volunteers harmless from any and all liabilities, actions,causes of action, debts, claims or demands of every kind and nature whatsoever which mayarise by or in connection with participation of my child in any activities related to the NJROTCprogram.

I certify that my child has no ailments or organic defect that would make participation in aNJROTC extra-curricular activity dangerous to his/her health. I also certify that there is aphysical on file with the school clearing my child to participate in NJROTC extra-curricularactivities.

A STUDENT MUST BE COVERED BY INSURANCE TO PARTICIPATE (EITHER FAMILY COVERAGE OR

INSURANCE PURCHASED FROM SCHOOL).

CHECK APPROPRIATE BOX

[ ] FAMTLY TNSURANCE

[ ] scHool rNsuRANcE

I fully understand that participation in a NJROTC extra-curricular activity does not guaranteemy child a grade in class andlor a place on any specialty team.

The terms hereof shall serve as a release for me, my heir, estate, executor, administrator,assignees, and for all members of my family.

Signature of Pa rent/G uardian Date

NAVAL JUNIOR RESERVE OFFICERS TRAININC CORPS(NJROTC)

STANDARD RELEASE T'ORM

I.

Date:

parent/guardian of. bcing thc lcgal

. a nreniber ofthc Navai Junior Rc-scrve Ofl'iccrs Trainins Corps. in considcration of the continurince of his/hernrenrbership in the Naval Junior Rescrve Officers J'rainine Corps atrcl/or his/her acceptancc ti;rNaval Junior Rcservc Officers Trainin-e Corps training, do herebv release l-rorn any and allclainrs. denrands. actions. or causes olaction. due to death. injurv. or illness. the govcntrncnt ofthe United States and all its officers. rcpresentatrves. and agents acting ol'ficialiy and also thcIocal. regional. and national Navv Ol-ficials of the United States.

I hereby' authorizc pcrsonnel ol the Deparllllent of Dcfensc, Armed Forces. PLrblic HealthService, or civilian physicians to rcndcr such medical and dental care as ntay be uecessary andrnedically indicatcd iu thc case of rny sorr/daughter/ward during his/hcr pcriod of training, as isdeemccl necessary by a qualit'icd practitioner.

I understand thal care at a ntilitary medical lacility for non-military dependenls ri,ill nornially berendercd on a tenrporary (ernergency) basis only: if turther care is indicated. the paticnt uillbctransferred to non-militar), carc as soon as possible. Erncrgcncy care providcd to caclcts who arcttot military depcnclenls at a rnilitary facility nrav be subjected to rcimbursenlcnt. and I nray hebilled for tltc care provided. For Navy Mcdical Department facilities, such care is ar-rthorized byNAVMEDCOMINST 6320.3B.

My son/daughter/u'ard has bccn dete rnrinc.d to have the following allcrgics:

Hc/she requircs nredication lor thc treiltrnent o[':

His/her physicianNamc:Add,ox:-

'felephone (inclucle arca coclc):

Below are listcd othcr rncdicul conditions which my sonidaughtcr/rvard is kno'"l'n to havc. which u,ouldpreclLrde or linrit in any rvay his/hc'r p{rrticipation in physical cxercise uncl athletic prosrarns.

CNET GEN 5800/4 (Rcv. l-00)

Init ials

Page I

lvledical InsuranceName:

Street:Clity. State, Zip Code:Policv/lD Nunrbcr:'l'elephone Cr-inf irntation Number: (

Dcntal Insurance Con.rpanv'i'Nante:

'fe onc (-'onfirrnation Nrrllber:

*'fhis insurance is not *q,rt..d. H-u"r.rt tt "

infobtain n0n-em care.

PRIVACY ACT NOTIFICATIONUnder the authorit-v ol-5 U.S.C. Sec. 301. the inlbrnration rcgarding your child's/ward's hcalth,medical condition and trcatnrcnt is rcquestcd in order to verify any need to administer medicatiorrand to cnable n-redical/dental persclnnel to cliagnose and trcat anv cnrergellcy conditton rvhichntay arise during training. Pursurnt to thc Privacy Act. 5 U.S.C. Scc. 552. the rcquestediltlbrmation will not hc divulged without vour *'ritten authorization to arlyone othcr thanNJROTC area personnel involved rvith adrninistration of NJROTC activitics and rnedical/dentalpersonnel requiring the inforrnalion in order to effectively {reat arly rnedical/dental problernwhich ntay arisc. Disclosure is voluntary: howcvcr. f'ailurc to provide the requcstcd inlbrnrationwill preclucle vour child's/waLcl's pafliciDution in the trainin

Signature of Parcnt or Guardian:

Address:

State:

F"l"pL,* ( rrct,,,te 0,"r, .',r.t";

Strect:City. State. Zip Code:Policy/lD Nurnbcr:

CNET - GtrN 580(y4 (Rev. 1-(X)r Page 2

7jp.

NAVAL JUNlOR RESERVE OFFICERS TRAINING CORPSEdward C. Reed Hight School, 1350 Baring Blvd, Sparks, NV 89434

Dance -^rtv Rules and Regulations1. No foul language permitted, in or around the school and/or NJROTC area.

2. No smoking on school property,

3. No one may leave the JROTC area without first checking with the chaperone on duty.Failure to do so means you're gone. You will not be readmitted back into thedance/Party. lf you are expelled from the dance and cannot get in touch with your ride,you will be assigned to ta classroom until your ride comes to pick you up.

4. All guests must have a valid student lD card. Guests may be asked to show their lD cardsby anyone of the chaperones at any time, before, during or after the dance.

5. Non-student guests must have expressed permission from the Naval Science lnstructorsprior to entering the dance.

6. Students must provide names of any guests, not a member of the Reed NJROTC, beforethe dance. NJROTC Cadets will list the guest's age, if older than 18 yrs., gender, schoolwhich guests attends, if otherthan Reed. Thiswill done bycompleting a school danceguest pass.

7. Cadets are responsible for their own actions and the behavior of their guests. lf theirGuests are expelled, then the Cadet will also be expelled from the dance.

Failure to abide by the above rules and regulations may mean a loss of your right to attendfuture dance/parties hosted by Reed NJROTC.

As a cadet I have read and understand the rules as set above.

Cadet's Name (Print) Cadet's Signature

Date

NAVAL JUNIOR RESERVE OFFICERS TRAINING CORPSEdward C. Reed Hight School, 1350 Baring Blvd, Sparks, NV 89434

Web Page Release Form

This is a request for permission to use any pictures of your child on the Reed High School NavyJROTC website. lmages are used to promote and highlight all cadets in the Reed High SchoolNavy JROTC program and to chronicle events throughout the year. All photos will be taken bystaff, fellow cadets, professionals and/or parents involved in the program. ln some cases thepictures will be accompanied by a caption listing the cadet(s) by name in the photo.

Please return this form to indicate that your child's picture may be used on the internet. Thispermission will stay in effect until cancelled by the parent or guardian.

Thank you for your cooperation.

As the parent or legalguardian, I grant the Reed High School NavyJROTC program thepermission to use my child's picture on the Reed High School NavyJROTC website(https://reednjrotc.weebly.com/) on the internet.

Yes, my child's name andf or picture may be used forthe Reed HS NJROTC website.

No, do not use my child's individual picture for the Reed HS NJROTC website. I willtellmy child to make every effort to avoid opportunities to be in group pictures.

Cadet's Name (Print) Parent/Legal Guardian's Name (Print)

Cadet's Signature Parent/Legal Guardian's Signature

Date Date

Area 13 HEALTH RISK SCREENING QUESTIONAIRE

CADET NAME:

SCHOOL NAME:

Date of cadet's most recent pre-participation sports physical:

PART A -TO BE COMPLETED BY THE CADET AND PARENT/GUARDIAN (Do Not Skip Any Question)

1. Haveyou had a medicalillness, injury or surgerysince your last check upor sports physical?

2. Do you have difficulty doing strenuous (great effort)exercise?

3. Doyouhaveamedical noticefromyourphysiciantoNOTtoparticipateinlongdistanceruns,suchas a L-mile-run?

4. Doyouhavea medical noticefromyourphysicianthatyouare NOTtodocurl-upsor push-ups?

5. Do you exercise lessthan three times per weekforat least thirty minutes?

6. Haveyouhadanybrokenbones,aseriousaccident,oranvtypeofsurgeryinthelastsixmonths?

7. Do you usetobacco of anykind?

8. Haveyouexperiencedchest,neck,jaworarmdiscomfortwhiledoingphysical activity?

9. Do you have difficulty breathing or have sudden breathing problems at night?

l-0. Has Asthma ever been documented in any of you r medical records growing up?

11. Do you currently have Asthma?

12. Are you using an inhaler to aid in breathing?

13. Do you experience any shortness of breath with relatively low levels of exercise orexertion?

14. Have you f elt any chest pain at rest?

15. Do your medical records contain any known cardiac (heart) disease?

16. According to the Navy's height/weighttable (page 4) are you overweight?

17. Hasyourphysicianslimitedanyactivityduetodizzy/faintingspells,frequentheadaches,orfrequent back pains?

18. Haveyoueverexperienceddehydrationafterstrenuousphysicalexercisethathasresultedinyourphysiclan now recommending or limiting certain physical actlvities?

19. Are you currently undertreatment by a physician or other medical practitioner?

Ev"rEr,lo

EvesEruo

EyesE r,lo

EvesEr'lo

EyesX r,lo

EVesE rrro

IvesIruo

EvesEruo

Ev"rEruo

EvesEruo

EYesf ttto

EverEruo

EvesE ttto

flYes fl ruo

IvesEt'lo

Ivetf] tlo

EvesEruo

Eves E ruo

Ev". E ruo

Area 13 HEALTH RISK SCREENING QUESTIONAIRE

CADET NAME:

SCHOOL NAME:

20. Hasyourmotherorsisterdiedwithoutanyexplanationorsufferedaheartattackbeforetheageof 55?

21. Hasyourfatherorbrotherdiedwithoutanyexplanationorsufferedaheartattackbeforetheageof 45?

22. Do you have high blood pressure orare you on blood pressure medication?

23. Has a doctor evertold you that you have high cholesterolor are you on cholesterol medlcation?

24. Do you have diabetes?

25. Have you experienced episodes of rapid beating or fluttering of the heart?

26. Do you sufferfrom lowerlegswelling of both legs?

27. ls there any history of metabolic disease (thyroid, renal, liver) listed in any of your medicalrecords?

28. Doyouhaveabone,joint,ormuscleproblemthatpreventsyoufromdoingstrenuousexercises?

29. Haveyouunintentionallylost/gainedmorethanl-0percentofyourbodyweightsinceyourlastPFA?

30. Have you everbeen diagnosed with Sickle Cell Trait?

31. Doyouhaveacurrentprescriptionforepinephrine(or"epi"pen)forsituational use?

32. Areyou currentlytaking any prescription or non-prescription (overthe counter) medicationsorpills?

33. Doyouhaveanycurrentskinproblems(forexample,itchlng,rashes,acne,warts,fungus,blisters,pressure sores, or bites) of anv kind?

lf Yes, Please specify:

34. Have you ever become ill from exercising in the heat?

Eves E trto

Ev"tEruo

EYesE ttlo

EvesEruo

EvesEruo

EyesE r,lo

EvesEruo

EY"rEr'lo

EY"rEruo

trvesEruo

EvesEruo

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Cadet's Signature/Date Pa re nt/G uard ia n's Signatu re/Date

Area 13 HEALTH RISK SCREENING QUESTIONAIRE

CADET NAME:

SCHOOL NAME:

PART B. TO BE COMPTETED BY A LICENSED MEDICAL PRACTITIONER

(lf any of the answe rs to the q uestions above we re YES, the fo llowing sectlon m ust be com pleted a nd signed bya licensed medical practitione r)

1. Listsignificantclinical historyand/orcurrentmedicationandtreatmentregimenoftheabovecadet:(Usebelowasnecessary)

2. Recommended/released for participation in strenuous physicalactivities including the mile run.

EY"r Eruo

Signature of Medical Practitioner Date

l3

Area 13 HEALTH RISK SCREENING QUESTIONAIRE

CADET NAME:

SCHOOL NAME:

Navy height and weight standards chart

Male

Height (inches) Maximum Weight Standard (pounds)

Female

Maximum Weight Standard (pounds)

57

58

59

60

6l62

63

64

65

66

67

68

69

70

7l

72

73

74

75

76

77

78

79

80

127

l3l136

l4l145

r50

155

t60

165

110

115

r8l186

t9t

196

20t

206

2tt2t6221

226

231

236

241

127

l3t136

1,tl

l,t5

t49

t52

156

I60

r63

t61

170

114

177

l8lr85

189

194

200

205

2t1

2t6222

227

4

FORM C

Dear Health Practitioner;

Enclosed is the revised Nevada lnterscholastic Activities Association (NIAA) packet for High School Pre-participation Physical Evaluations (PPE's). You willnotice that the form we are using incorporatesrecommendations from the Second PPE, Task Force (1997)(supported by the AAFP, AAP, AMSSM, AOSM andAOASM) and separately from the AHA. We anticipate that this form will be reviewed every few years and we willkeepyouapprisedofanychanges. Also,foryoungathleteswithknowncardiovascularabnormalities,werecommend following the guidelines of the 26th Bethesda Conference. We recommend you reference the TaskForce monograph, the AHA recommendations or the 26tl' Bethesda Conference before performing high schoolathletic physicals in Nevada.

While many of you have been performing these evaluations for years. we would like to bring your attention to a f-ewpoints. As discussed in the introduction to the monograph, there are multiple reasons for performing PPE's; theforemost reasons are to prevent injury and sudden cardiac death.

It is estimated that between I and 2 deaths (predominantly cardiovascular in etiology) per 200,000 high schoolathletes occur per year. The prevalence ofcardiovascular disease capable ofcausing sudden cardiac death in theseathletes is around l/20,000. The most common cause of cardiac death in this population is hypertrophiccardiomyopathy (HCM).

Since the vast majority of PPE's will be completely normal, and, conversely, most students with abnormalities onhistory or physical exam do NOT have significant cardiac pathology, extreme diligence is required whenperforming these exams so that the few students with serious conditions are not missed.

ANSWERS ON THE HISTORY FORM THAT WOULD SUGGEST A NEED FOR A CARDIOLOGYCONSULTATION INCLUDE:r Excessive shortness of breath, syncope or chest pain during exercise,o Family history of premature death or cardiovascular morbidity. (Before age 50)o Family history of HCM, dilated cardiomyopathey, long QT syndrome, or Marfan's syn4rome.

ABNORMALITIES ON THE PHYSICAL EXAM THAT SUGGEST THE NEED FORECHOCARDIOCRAPHY OR CARDIAC CONSULTATION INCLUDE:. Any systolic murmur greater than IIIVI.. Any diastolic murmur.o A murmur that increases in intensity from supine to standing (suggests HCM).o Stigmata of Marfan's syndrome. (Attachment 7).

A second goal of the PPE is to detect chronic illnesses or old injuries that rnay hamper the athlete's perfbrrnance(such as Exercise Induced Asthma) or lead to injury ("the most common cause of injury is reinjury").

The final goal of the PPE is to provide our young athletes with a chance to talk to a physician about health issues.While this exam does not replace ongoing care by a personal physician, it may be the only contact these studentshave' Therefore, a brief discussion of health issues such as breast and testicular cancer screen ing. alcohol andtobacco use, automobile safety, etc., may be appropriate during the ppE.

Thank you for your willingness to help ensure a safer future for Nevada's young athletes.

Published by the NIAA Sporls Medicine Advisory Commirtee.

Approved: February 2000; June 2012Over >

FORM D -- Health Practitioner, please refer to the letter & references provided on Form C.NIAA PRE-PARTICIPATION PHYSICAL EVALUATION

Ph to be comnleted du an athletes first and third year of rrartici tionPHT'SICAL EXA]IIINATION

DATtr OI- hXAMINAI ION

DATF- oIi I]IR1'I I

HEIGHI' WEIGHT: _ 9n BODY FAT (optional): _ I)[JLSE: _ BI,: i ( i )

VISION: R 20i CORRT'.CI lrl) Y, N PtJPll.S: tlualNORMAL/ABSENT

ABNORNIALFINDINGS

INITIALS

es/EarsNose/Throat

Cenitalia (Males On

Murmur that lncreasesFrom Supine to StandinSystolic Murmur GreaterThan II/VI

Diastolic MurmurRadial & Femoral Pulses

Shoulder / ArmE,lbow / ForearmWrist / Hand

Stigmata of Marfan's

CLEARED after completing evaluation/rehabilitation for:

NOT CLEARED FOR:Recommendations:

REASON:

Name of physician (print/type):

Address:

Phone:

I,

Street City State Zip Code

ualified to perform NIAA Pre-hereby certify that I am a licensedParticipation Evaluations, and that on the date set forth below I performed all aspects of the NIAA Pre-Participation Evaluation onthe atrove student. This student meets all physical examination requirements for participation in NIAA sanctioned sports.

Signature of HealthRevised 5-20101 June

Practitioner2012

License Number Office Phone Number Date

NAME:

I n!'.lual