4150 South M-52 Owosso, MI 48867 Phone: 989-725-2391 Fax: 989-729-6408

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4150 South M-52 Owosso, MI 48867 Phone: 989-725-2391 Fax: 989-729-6408

STUDENT AND PARENT OR GUARDIAN
SPORTS PHYSICAL & PHYSICIAN CONSENT FORM
A current-year physical is one given on or after May 15 of the previous school year.
PLEASE PRINT
COMPLETE Last First Middle
LEGAL NAME:
DATE OF Month Day Year PLACE OF City State
BIRTH: / / BIRTH

GRADE: 9 10 11 12 SCHOOL:
STUDENT PARTICIPATION
This application to participate in athletics is voluntary on my part and the information submitted is truthful
to the best of my knowledge.
I have never received money or negotiable certificates for merchandise in any amount, nor any emblematic
award or merchandise worth more than fifteen dollars ($15.00) for participating in athletic events, nor have
I ever competed under an assumed name. After I have represented my high school in any sport, I promise
not to compete in any outside athletic contest in this sport until after the high school season has been completed.
I understand that I am expected to adhere firmly to all established athletic policies of my school district and
the Michigan High School Athletic Association, such as those previously mentioned above as examples but
which do not represent all the policies to which I am subject.
______
SIGNATURE OF STUDENT DATE
PARENT OR GUARDIAN OR 18-YEAR OLD CONSENT
I hereby give my consent for the above high school student to engage in interscholastic athletics in
MHSAA approved sports and understand the possibility that serious injury may result from participating in
athletic activities. He/she has my permission to accompany the team as a member on its out-of-town trips.
I further understand that my son or daughter will be expected to adhere firmly to all established athletic
policies of the school district and the Michigan High School Athletic Association.
______
SIGNATURE PARENT OR GUARDIAN DATE
OR 18-YEAR OLD
THIS FORM MUST BE ON FILE IN THE HIGH SCHOOL
OFFICE BEFORE PRACTICING WITH ANY ATHLETIC TEAM.
(Please Print)
EMERGENCY INFORMATION—To be completed by Parent or Guardian or 18-Year old.
Student’s Name:______Grade:______
In Emergency 1)______Phone:______
Contact: 2)______Phone:______
My Family Doctor is:______Phone:______
Any Special Medical Information:______

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4150 South M-52 Owosso, MI 48867 Phone: 989-725-2391 Fax: 989-729-6408N

Michigan High School Athletic Association, Inc.

MEDICAL HISTORY
• To be completed and signed in three places by parent or guardian or 18-year old.
A current-year physical is one given on or after May 15 of the previous school year.
Last First
NAME: / Sex / Grade / Age / Date of Birth
S Street
ADDRESS: / City / Zip
Father/Guardian Name / Work Phone / Mother/Guardian Name / Work Phone
Family Doctor Office / Office Phone / Home Phone / Date of Birth
Insurance Statement
Our son/daughter will comply with the specific insurance regulations of the school district.
• Family Insurance Company:______Contract No:______
• Signature of Parent or Guardian or 18-year old:______
History / Yes / No / History / Yes / No / History / Yes / No
Have you ever had fainting / Heart Disease / Do you have blurred vision
Diphtheria / Kidney Disease / Headaches
Scarlet Fever / Tuberculosis / Convulsions
Rheumatism / Jaundice / Blackouts
Rapture / Cough / Painful Joints
Rheumatic Fever / Nosebleeds / Backaches
Pneumonia / Frequent Sore Throats / Pounding of Heart
Asthma / Stomach Pains / Shortness of Breath
Diabetes / Frequent Urination
Physical Examination
To be completed by the examining MD, DO, Physician’s Assistant or Nurse
SYSTEM / Normal / Abn. / SYSTEM / Normal / Abn. / SYSTEM / Normal / Abn.
Urinalysis / Throat / Heart
Vision / Teeth-Cavities / Abdomen
Blood Pressure / Orthopedic / Hernia
Pulse Rate / Thyroid / Genital/Testicular Exam
Ears / Chest / Neurologic
Nose / Lungs / Muscular
Recommendations:______
I certify that I have examined the above student and recommend him/her as being able to compete in supervised athletic activities not checked below:
__BASEBALL__BASKETBALL__COMPETITIVE CHEER__CROSS COUNTRY__FOOTBALL__GOLF__GYMNASTICS
__ICE HOCKEY__SKIING__SOCCER__SOFTBALL__SWIMMING__TENNIS__TRACK__VOLLEYBALL__WRESTLING
A current year physical is one given on or after May 15 of the previous school year.
SIGNATURE OF EXAMINER:______MD __ DO __ PA __ NP
PRINTED NAME OF EXAMINER:______
Medical Treatment Consent—To be completed by Parent or Guardian or 18-year old
I, ______, (an 18-year old) the parent or guardian of ______recognize that as a result of athletic participation, medical treatment on an emergency basis may be necessary, and further recognize that school personnel may be unable to contact me for my consent for emergency medical care. I do hereby consent in advance to such emergency care, including hospital care, as may be deemed necessary under the then-existing circumstances and to assume the expenses of such care.
SIGNATURE OF
PARENT/GUARDIAN/18-YEAR OLD:______Date:______

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