Wallkill Valley Regional High School District
10 Grumm Road, Hamburg, NJ 07419
Phone (973) 827-4100 Fax (973)827-8318
Edward Bolcar-Superintendent
Taryn
Benacquista David
Carr
John J. Mayer
Interim Vice Principal Assistant Principal Director of Student Personnel Services
HEALTH UPDATE
Dear Parent/Guardian:
Your son/daughter has had a physical examination to participate in a
previous interscholastic activity during this school year. Before he/she may participate again, we require that the information requested below be completed.
The medical department at Wallkill Valley Regional H.S. will review this information and if there are any questions about the present condition of the candidate another physical examination or clearance from your family physician will be required.
Please complete the form below, sign and return the form to the Health Office as soon as possible.
SPORT:___________________________________________________________________
Name__________________________________________Date of Birth________Grade_____
Participated in_________________________________during__________________________
(Sports or activity) (Season)
Since the physical examination on __________________(Date),my son/daughter has
experienced the following: if none. Please state none. Please include name of Physician(s)
and dates(s).
Visits to Doctor:_____________________________________________________________
Illnesses:___________________________________________________________________
Injuries:____________________________________________________________________
Medication prescribed:________________________________________________________
Additional immunizations:______________________________________________________
__________________________________________________________________________
(Parent/Guardian Signature) (Date)
Your son/daughter WILL NOT be approved for participation unless signed by parent/guardian.