Student 

Sport/Activity

Parent/Guardian

Home phone

Home address

Cell phone

Emergency contact (relationship to student)

Contact phone

Physician

Physician phone

Medical History:

Date of Birth:    

Height:        

Weight:        

☐ Heart condition    ☐ Diabetes    ☐ Asthma:     ☐ Requires child to self-administer medication

☐ Epilepsy                ☐ Allergies:     ☐ Requires student to carry EpiPen®

☐ Other                                            

List all medications (prescribed and over the counter)

Injuries (brief description and dates)

Surgeries (brief description and dates)

Physical activity restrictions (brief description and duration)

I certify that:

1. My child is in good health and is capable of participating in the above sport or activity.  No need exists to limit his/her participation.  I assume full responsibility for his/her physical condition and participation, and will notify you of any changes.

2. I have completed and submitted the Authorization for Medical Treatment form allowing the school to seek medical treatment for my child in the event of a medical emergency when reasonable attempts to contact me are unsuccessful.

3. If my child requires or may need medication while participating in athletics, I have completed and submitted the School Medication Authorization Form.

Parent/Guardian signature

Date