A Communicable Skin Disease Form must be processed listing the name, birth date, and school of a wrestler competing in any PJW tournament after being diagnosed as having a communicable skin disease or being suspected of having a communicable skin disease or any other condition that makes participation appear inadvisable. The PIAA form may be used in place of the PJW form.

Please describe the skin condition of ________________________________ (name of wrestler), whose

date of birth is ______/______/______, and is a pupil of _______________________________school.

  1. Indicate the specific location(s) of the suspected skin condition on the figures below and describe its location(s). Examples: behind right ear; left hand, between thumb and index finger.

  2. Describe the approximate size and color of the above condition. Examples: about the size of a nickel, red in color: about two inches in diameter, blotchy red.

    3. ______________________________________________________________________________

    ______________________________________________________________________________

  3. Technical name of skin condition (diagnosis): __________________________________________
  4. Do you believe the skin condition is contagious or harmful to others? YES NO circle one

    5. If yes, is the skin condition under current therapy or has it been treated? YES NO circle one

  5. If contagious, on what date will the wrestler’s participation no longer be harmful to his opponent(s):

    6. ________/________/________?

  6. The authorization to return to competition expires on ________/________/________
 

 

Print Physician’s name: ______________________________ License no. ______________________

Print Physician’s specialty area: _______________________________________________________

Print Physician’s address: ____________________________________________________________

____________________________________________________________

____________________________________________________________

Print Physician’s telephone number: ( ) ___________________________________________

Physician’s signature: _____________________________________ Date _______/_______/_______

 

 

NOTE TO PARTICIPANTS, TOURNAMENT DIRECTORS, COACHES, OFFICIALS

Pennsylvania Junior Wrestling observes P.I.A.A. and National Federation Wrestling Rules. The following is the National Federation Wrestling Rule relevant to communicable skin disease:

Rule 4-2-3: If a participant is suspected by the referee of having a communicable skin disease or any other condition that makes participation appear inadvisable, his coach shall provide current written documentation from a physician stating that the suspected disease or condition is not communicable and that the athlete’s participation would not be harmful to his opponent. This document shall be furnished at the weigh-in or upon arrival at the site of the dual meet or tournament. Covering a communicable condition shall not be considered acceptable and does not make the wrestler eligible to participate.

 

 

 

 

 

 

PJW_Form: csd_012799