Forms for Student-Athletes
    @ Roxbury High School

    for the 2020-2021 school year

  • Health Folder
    Dear Parent(s)/Guardian(s):
    Congratulations on making the commitment to participate in the Roxbury High School Athletic Programs.  These programs have a tradition of excellence and teach many valuable lifelong lessons.  Please understand that successful participation will require a high level of dedication, responsibility, and diligence.  I hope that all participants have a positive and rewarding interscholastic experience.
    New Jersey State Law mandates that the school physician must check all sports physicals and sign the physical form prior to a student participating on any athletic team.  No student will be allowed to participate in interscholastic sports (including tryouts and practices) until the school physician has signed the student's new physical exam form. 
    It is imperative then that all of the paperwork and forms explained below on this webpage are completed and returned in a timely manner to ensure approval and eligibility for sports participation.  Late submission will result in participation penalties; click here for an outline of these consequences.
  • Important Note Deadlines

    All paperwork and forms outlined below on this webpage must be completed no later than the dates indicated in the following table to ensure approval and eligibility for participation:
    School Year Sports Season 
    Due Date for Forms
    July 20, 2020 (Mon)
    Nov 16, 2020 (Mon)
    TBD, 2021
  • Important Note Paper Forms

    Highlighted in yellow below are forms to be printed, completed, and submitted once per year, prior to the start of your child's first sports season:

    1. Pre-Participation Physical Evaluation Form and Clearance Form (referred to as Pre-Participation Form B)-  This link contains two pages:

    Page 1 is a Physical Evaluation Form:

      • Parent and student are asked to complete the top of this page with the student's name and date of birth.  
      • Your physician must complete all other areas on Page 1:
        • Your physician must record the student's height, weight, blood pressure, pulse, vision, review of systems, and clearance level.
        • Your physician must sign and stamp the bottom of Page 1 as the physician/provider.
        • Your physician must record the date of the physical exam.  The date of the physical exam:
          • must be written by the physician at the bottom of Page 1 next to the physician's signature; and
          • must have been performed:
            • on or after Aug 11, 2019 for Fall 2020 season participation; and on or after Dec 2, 2019 for Winter 2020 season participation.
            • if you are unsure if the date of your child's physical will be valid at the start of the season or if your child participated in a sport the prior season, and you are unsure of what needs to be submitted, please contact your School Nurse by email, or have your child inquire at the health office.
      • Vision must be completed and documented by the physician or an ophthalmologist's report must be attached (if the vision is not completed the athlete will not be cleared).  

    Page 2 is a Clearance Form:

      • Your physician must complete this page, stamp, and sign as the physician/provider. 
      • Additionally, a second physician signature is now required at the bottom of the Clearance Form that designates the cardiac module was completed.   

    Both Page 1 (the Physical Examination Form) and Page 2 (the Clearance Form) will be kept on file in the nurse's office.

    1. School Physician's Notification of Sports Participation-  This form is required for new physicals only.  Parent and student are asked to complete the top of this page, and then submit this with a self-addressed stamped envelope with name of parent/guardian and complete mailing address.

    Highlighted in blue below are forms REQUIRED to be printed, completed, and submitted for each sports season your child participates in an activity:

    1. Health History Questionnaire (referred to as Pre-Participation Form A)-  
      • The entire form must be filled out by parent and student and may not be dated more than 60 days prior to the start of practice.
      • Any "yes" answers to questions 1-54 must be explained at bottom right of the form.
      • The form must be signed by the parent and student.

    2. COVID-19 Questionnaire  
      • This questionnaire must be completed seven (7) days prior to the start of the first workout session. This form only needs to be completed one time.
      • Any athlete who does not have a COVID-19 Questionnaire on file will not be permitted to participate.

    3. Emergency Contact Form-  
      • Please fill out all information on the top only (leave the bottom portion blank).  
      • Both the parent and the student must sign this form.

    Highlighted in orange below are additional forms required to be printed, completed, and submitted for students who have been diagnosed with asthma (Asthma Treatment (Action) Plan), life threatening allergies (Anaphylaxis Action Plan) and other medical conditions.  Note: These forms are due yearly even if a student does not participate in co-curricular activities and must be dated on or after July 1, 2020:

    1. Anaphylaxis Action Plan

    2. Asthma Treatment (Action) Plan

    3. Seizure Action Plan

    4. Annual Update form for Medical Condition

    5. (if applicable):  Clearance notes for injuries provided to you by your physician
  • We look forward to the upcoming athletic seasons and wish all students, advisors, coaches, and parents/guardians the best of luck for a successful and healthy season.  If you do not have a medical home or if you have a question regarding the sports medical clearance process, please do not hesitate to contact my office at 973-584-1200 ext. 1230.
    Stuart Mason
    Director of Athletics and Student Activities 

    Late Submission Penalties
    Sport physical forms that are submitted after the due date will be subject to the following consequences:
    • Within the first school week of due date: 
      Athlete will NOT be allowed to participate in his/her sport for 1 DAY after he/she has been cleared to participate.

    • Within the second school week of due date:
      Athlete will NOT be allowed to participate in his/her sport for 2 DAYS after he/she has been cleared to participate.

    • Within the third school week of due date:
      Athlete will NOT be allowed to participate in his/her sport for 1 WEEK after he/she has been cleared to participate.

    • Within four or more school weeks of due date:
      Athlete will NOT be allowed to participate in his/her sport for 2 WEEKS after he/she has been cleared to participate.

    Please note:
    • In accordance with NJ State Law, the school physician has been contracted by our Board of Education to visit our school 3 times per pre-season.

    • The sole purpose for each of these visits is to review and sign off new sports physicals.  This does not include already existing valid sports physicals on file in the health office.

    • These 3 visits generally fall within the 4 week time frame of the stated due dates.  Therefore, if new physical forms are turned in later than the last contractual visit made by our school physician, it will be the athlete's responsibility to incur any additional costs should another visit by the school physician be required to clear those forms submitted after the deadline.