Clifton T. Barkalow Middle School

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Health Office

 
School Nurse: Mrs. Larisa Ippolito, RN
email: lippolito@freeholdtwp.k12.nj.us
Phone: (732) 431-4403 Ext: 2108
 
**IMPORTANT PLEASE READ**


2017-2018 SCHOOL YEAR
 


The Scholastic Student-Athlete Safety Act (SS-ASA) (N.J.S.A. 18A:40-41.7) mandates that sports physicals may ONLY be completed by a licensed physician, advanced practice nurse (APN) or physician assistant (PA) who has completed the Student-Athlete Cardiac Assessment professional development module.

The licensed physician, APN or PA, must sign the certification statement on the Pre-participation Physical form attesting to the completion of the professional development module.

Physical forms will not be accepted without the healthcare provider’s signature in the certification statement section.

The student will not be cleared to participate in their sport unless your healthcare provider completes the Student-Athlete Cardiac Assessment professional development module AND signs the certification statement on Page 4.

It is recommended that you verify that your medical provider has completed this module before scheduling your sports physical appointment.
 
 
THE DEADLINE TO TURN IN FORMS FOR WINTER SPORTS IS October 31, 2017.

 
THE WINTER SPORTS SEASON STARTS ON NOVEMBER 14th
 
Exams conducted on or after 11/15/16 are acceptable for the WINTER 2017-18 season.
 
 
The Annual Athletic Pre-Participation Physical Examination Forms are required by the New Jersey Department of Education. These forms are required for any middle or high school student in New Jersey who wants to participate in an interscholastic or intramural sports program. Students must have their exam approved by the school doctor before they can participate in practice or tryouts. Our school doctor is scheduled in advance to review all the sports physicals for the entire district. Forms that are submitted late or incomplete cannot be guaranteed to be approved by the school physician before the season starts. Students who have not received clearance by the school doctor may not participate in any practice or tryout. Please adhere to all deadlines and guidelines to ensure that your child is able to participate.

HISTORY FORM
  • Must be completed in full by the PARENT/GUARDIAN
  • Must explain all “yes” answers; include dates, length of symptoms and treatment. You may attach a second piece of paper if more room is needed
  • The parent/guardian and student must sign and date
  • The date on the History form must be the same date as the physical exam *This form must be reviewed by the health care provider at the time of examination
 
 
SPECIAL NEEDS SUPPLEMENTAL HISTORY FORM
 
 
  • Must be completed and signed by the parent/guardian even if the student does not have a disability
  • The parent/guardian and student must sign and date

 
PHYSICAL EXAMINATION FORM & CLEARANCE FORM
 
  • Must be completed in full by the HEALTH CARE PROVIDER
  • Both forms must be signed, stamped and dated by the health care provider
  • All “indicators” must be filled in by the examiner; this includes height, weight, blood pressure, pulse and vision.
  • Health care provider signature in the Cardiac Assessment Professional Development section.
  • INCOMPLETE FORMS WILL BE RETURNED FOR COMPLETION BY YOUR HEALTH CARE PROVIDER PER NEW JERSEY ADMINISTRATIVE CODE.
  • Exams conducted on or after 11/15/16 are acceptable for the WINTER 2017-18 season.


Health History Update Questionnaire (blue form)
 
  • This form must be submitted if a valid physical is already on file in the health office.
  •  Dated no more than 90 days from the first practice/tryout
  • Must be completed in full by the PARENT/GUARDIAN
  • Complete 1 form per season not sport.
 
 
IMPORTANT INFORMATION REGARDING SCHOOL ATTENDANCE
(See attachment below for Spanish version)
 
As you are aware, the State of New Jersey has revised the laws regarding school attendance. In order to be in compliance with these laws, the Freehold Township Schools have created board policy to govern student attendance in Freehold Township. A summary of the policy can be found in the student handbook you received in September.

School board policy requires that the school receive a written note for each school absence with the parent's original signature. This note should state the date and reason for absence. We have created a form which may make it easier for you to fill out and send in the required information. You can complete the form in place of a note and return it the day your child returns to school. Immediately following any future absences, you can always refer to this site to access the form or you may write an absence note to your child's teacher. We appreciate your cooperation with this policy.
 
 
See Below for Absence Form

CTB Absence Form

Sports Forms
Human Papillomavirus:
Information from the New Jersey Department of Education
Sudden Cardiac Death Brochure