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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 _______________________

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