Participation Health Screening
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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 _______________________
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.
PHYSICIANS SIGNATURE _______________________________________________________
DATE ____________________ ___________School Year