There are FIVE sections that need to be MUST be completed prior to participating

1. History Form (THIS CAN BE DONE DIGITALLY IN DRAGONFLY MAX or Printed, signed-scanned–& uploaded)

• a. This form is completed by the student-athlete and his / her parents or guardian.

• b. Both the athlete and a parent or guardian should sign this form.

2. Physical Examination Form

• a. This section is completed by and signed by a licensed medical professional (MD, DO, NP, or PA-C).

• b. The physical exam should include a thorough review of the history form. The licensed medical professional should ask any clarifying questions or discuss any areas left blank in the medical history during the physical exam.

• c. This form should be signed on the date that the physical examination was completed. 

3. Medical Eligibility

• a. This section is completed, SIGNED & STAMPED by the licensed medical professional who reviewed the history form and completed the physical exam. 

• b. The licensed medical provider should complete the Shared Emergency Information based on findings from the history form and the physical examination. 

• c. This form should also be signed on the date that the physical examination is completed.

4. NCHSAA Gfeller-Waller Student-Athlete & Parent/Legal Custodian Concussion Information Sheet (THIS CAN BE DONE DIGITALLY IN DRAGONFLY MAX or 

Printed, signed-scanned & uploaded

5. NCHSAA Eligibility, Consent to Participate and Release Form (THIS CAN BE DONE DIGITALLY IN DRAGONFLY MAX or Printed, signed-scanned–& uploaded

Please remember we can always be reached should you have any questions at Kiser Middle School  

 716 Benjamin Parkway, Greensboro, NC 27408P: 336-370-8240 F: 336-370-8248