NORTH ALLEGHENY SPORTS NETWORK Athletic Director

Comprehensive Initial Pre-Participation Physical Evaluation (CIPPE)

Section 1 – Personal and Emergency Information:

Ø             This section needs to be filled out by the student’s parent/guardian and turned in to the Athletic Office each time that student is trying out for a sport, whether it be a fall, winter or spring.  If that student is involved in a fall, winter and spring sport, we should have (3) of these forms on file.

Section 2 – Certification of Parent/Guardian:

Ø             This section needs to be filled out by the student’s parent/guardian and turned in to the Athletic Office each time that student is trying out for a sport, whether it be a fall, winter or spring.  If that student is involved in a fall, winter and spring sport, we should have (3) of these forms on file.

Section 3 – Health History:

Ø             This section needs to be filled out by the student’s parent/guardian and turned in to the Athletic Office each time that student is trying out for a sport, whether it be a fall, winter or spring.  If that student is involved in a fall, winter and spring sport, we should have (3) of these forms on file.

Section 4 – PIAA Comprehensive Initial Pre-Participation Physical Evaluation & Certification of Authorized Medical Examiner:

Ø             This section should be filled out by either your family physician or our school doctor.  Please make sure there is an authorized signature and date at the bottom of this page.  Your paperwork will not be accepted without both the signature AND date.

Ø             An “authorized physician” includes: a licensed physician of medicine or osteopathic medicine, a certified registered nurse practitioner or a certified physician’s assistant.

Ø             With a valid physician’s signature and date on this section within one calendar year from the start of a fall, winter or spring sport season is all that is required unless there has been a change in the health of the student-athlete or he/she has sustained an injury since the initial physical evaluation. 

Ø             If there has been an injury or change in health since the initial evaluation, before the student can be cleared to participate in a subsequent sport season, they must have their doctor fill out Section 6 of the CIPPE.

Section 5 – PIAA Re-Certification by Parent/Guardian:

Ø             This section needs to be filled out by the student’s parent/guardian and turned in to the Athletic Office each time the student is trying out for his/her 2^nd or 3^rd sport season.  It is not required for the initial sport.

Section 6 – PIAA Comprehensive Pre-Participation Physical Re-Evaluation and Re-Certification by Authorized Medical Examiner:

Ø             This Section needs to be filled out by your family doctor or school doctor ONLY IF the student-athlete has sustained an injury since the initial evaluation or his/her health has changed.  If the student-athlete is in good health and has been since the initial physical evaluation, there is no need to have your doctor fill out this section.

Section 7 – CIPPE Minimum Wrestling Weight Classification:

Ø             All student-athletes participating in wrestling must complete this section no earlier than 6 weeks prior to the first practice date of the winter sports’ season.

Insurance Waiver Form – Section 8:

Ø             This section needs to be filled out and signed by the student-athlete and his/her parent/guardian before EACH participating sports’ season.  If the student is participating in a fall, winter and spring sport, we should have three of these forms on file in the Athletic Office.

Ø             This form is under a separate attachment on our website from the CIPPE information.

INITIAL SPORT PHYSICALS (Represents the first sport an athlete intends to play in a school year)

Must include:    Section 1

                                    Section 2

                                    Section 3

                                    Section 4

                                    Section 7 – For wrestlers only (to be completed 6 weeks prior to start of season)

                                    Section 8 – Insurance Waiver Form

RE-CERTIFICATION PHYSICALS – WITHOUT INJURIES (Represents all subsequent sports’ seasons in a school year provided there have been no injuries to the athlete from the initial evaluation)

Must include:                Section 5

RE-CERTIFICATION PHYSICALS - WITH INJURIES (Represents all subsequent sports’ seasons in a school year when the athlete has sustained an injury or change in health since the initial evaluation)

Must include:                Section 5

                                    Section 6 (Requires a doctor’s signature and updated date)

QUESTIONS SHOULD BE ADDRESSED TO ATHLETIC DIRECTOR BOB BOZZUTO AT 724-934-7238