PARTICIPATION HEALTH SCREENING

Required annually in addition to school physical

 

Student Name  _________________________________      Grade _________________  

                                                                                               

Home Address __________________________________________________________                                                                          

Phone  _________________  Parent's Work ________________  Cell ______________             

Student Soc. Sec. Number ____________________________ DOB ________________                           

Father's Name _______________________ Mother's Name _______________________                         

                                                                                               

MEDICAL CONCERNS/RESTRICTIONS                                                                                                                                                                                                                                                                                                                                                                                                                                                               

 

CURRENT MEDICATIONS                                                                                  

                                                                                                                                                                                                                                            

 

I understand a sports health screening is necessary for my child's participation in _________________________ Catholic School Extra-curricular Sports Program. 

I further understand that competitive athletics may result in injury although the school has and will do all it can to reduce the risk of injury.  I request a                                           Catholic School representative to obtain medical treatment for my child in the unlikely event of injury or illness during practice or games and I agree to pay any expenses incurred for such treatment.                                                                                                

 

SIGNATURE OF PARENT/GUARDIAN                                                                                                                                                                             

JOINT Custodial PARENT SIGNATURE                                                                                                                                                                             

                                                                                               

EXAMINING PHYSICIAN'S CERTIFICATE

                                                                                               

I hereby certify that I have examined                                                    on the date indicated below.  Based on the past health history s/he has given me and on my physical examination I find this athlete physically able to participate in interscholastic sports.                                                                                            

 

Any Restrictions?                                                                                                                                                                                                                   

 

PHYSICIANS SIGNATURE                                                  DATE                                               

___________School Year