PREPARTICIPATION PHYSICAL EVALUATION -- …
PREPARTICIPATION PHYSICAL EVALUATION -- MEDICAL HIS TORY REVISED 12-4-14 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 i f the student has developed any condition which would make i t hazardous to participate in an athletic event. Student's Name: (print) Sex Age Date of Birth Address Phone Grade School Personal Physician Phone In case of emergency, contact: Name
PREPARTICIPATION PHYSICAL EVALUATION -- MEDICAL HISTORY REVISED 12-4-14 This MEDICAL HISTORY FORM must be completed annually by parent (or guardian) and student in order for the student to participate in athletic activities.
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