Form - Physical Evaluation - Participation

Please fill out the form below.

This MEDICAL HISTORY FORM must be completed annually by parent (or guardian) and student in order for the student to participate in athletic activities. These questions are designed to determine if the student has developed any condition which would make it hazardous to participate in an athletic event.
Student's Name*
First Last
Sex*
Age*
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address City State ZIP Code
Phone*
Grade*
School*
Personal Physician*
Personal Physician Phone*
In case of emergency, contact:
Name*
First Last
Relationship*
Phone*
Type of Phone*
Explain "Yes" answers in the box below**. Circle questions you don't know the answers to. Any Yes answer to questions 1, 2, 3, 4, 5, or 6 requires further medical evaluation which may include a physical examination. Written clearance from a physician, physician assistant, chiropractor, or nurse practitioner is required before any participation in UIL practices, games or matches.
Comments
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Heritage Academy Maricopa