Winter Interval Form - Middle School (2018)
New York State Education law requires, prior to the start of EACH SEASON (Pre-Sports, Fall, Winter, and Spring), an Interval Health History to be submitted unless the student received a full medical examination within 30 days of the start of the season.  This review covers only the time since the student athlete's most current physical exam, dated within one year, which must be on file in the Health Office. TRY-OUTS are included in the regulation.
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Student Information
Student Last Name *
Student First Name *
Grade *
Winter Sport *
Interval Health History
INFORMATION TO BE PROVIDED BY PARENT OR GUARDIAN/ Medical Provider input NOT REQUIRED
NOTE: A “YES” response to any of these questions does not mean automatic disqualification from activity. However, it may require a review by the School Nurse or approval by a physician before the student may participate.
Date of Birth *
Date of most recent FULL physical exam *
AFTER the date of the medical exam dated above, has the student athlete experienced of any of the following?
Please check all conditions that apply.
For selected conditions, please provide additional details.
Include dates. As a result was the student seen by a MD?
Specifically during or after EXERCISE, has the student experienced any of the following symptoms?
(Rev. 4/22/10)
As a result of the above checked symptoms, was a Medical Evaluation done?
Yes or No. What was the result of the exam?
Health information may be shared with appropriate members of the educational team for use in meeting the student's health and educational needs. This will be on a “need to know” basis, in a confidential manner and may include communication with health provider to facilitate this process.  In the event of serious illness or injury the student may receive first aid or transportation by EMS to an Emergency Department for evaluation and treatment including X-ray and required tests to treat the student.  Every attempt will be made to contact parents first.  When necessary, the alternate contact or designated school employee may act in the interest of the student on behalf of the parent.
Electronic Signature of Parent/Guardian *
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