Blue Medical Form printable pdf download

Name and town of school attended last year:_______________________________

PARENT/GUARDIAN: PLEASE FILL OUT BOTH SIDES OF THIS FORM

This form plus a physical exam or sports physical form must be on file with the school Nurse BEFORE the student athlete

May practice or play a sport. Physical exams are valid for thirty six (36) months from the date of the exam.

SECTION 1: To be completed by STUDENT

STUDENT AGREEMENT:

Name: _________________________________________

Date of Birth: _________________

Grade: _____________ Sport: ________________

For High School participation:

This application to compete in supervised interscholastic athletics for the above named school is entirely voluntary on my part.

Signature of student: _______________________________________________

Date: ______________________________

SECTION 2: To be completed by PARENT/LEGAL GUARDIAN

Parent/Guardian’s permission: I give consent for the above named student to participate in the inter scholastic athletics for

The __________ school year, and to accompany the team, as a member, on trips to any inter scholastic games and consent

to the necessary transportation for such trips.

I understand that athletics involve the potential for injury which is inherent with any sport. I am aware that even with the best

coaching, supervision, protective equipment an strict observation of the rules that there is still a potential for injury.

On rare occasions, injuries could result in total disability or death.

Signature of Parent/Legal Guardian: _____________________________________________

Date: _____________________________

Home address: __________________________________________________

Email: ____________________________________

Phone (H): ________________________

(W): _____________________________

(C): _______________________________

Emergency Contact #1 Info:

Name: _________________________________

Relationship: _______________________________

Phone (H): ________________________

(W): _____________________________

(C): _______________________________

Emergency Contact #1 Info:

Name: _________________________________

Relationship: _______________________________

Phone (H): ________________________

(W): _____________________________

(C): _______________________________

SECTION 3: To be completed by PHYSICIAN

I have reviewed the health history provided by the parent on the reverse side of this form.

MEDICAL RELEASE: I certify that I examined this student on ____________, and that based on this exam, the student is cleared

to participate in all sports for the _______________ school year with the following restrictions. ______________________________________________

_________________________________________________________________________________________________________________

Does this student athlete need an EPIPEN? Yes___ No___ If yes, for what allerg?: ____________________________________________________

Does this student athlete need an inhaler? Yes___ No___

If yes to either question, I have completed and signed medication authorization form(s) for each medication.

Physician Stamp

Additional recommendations: ________________________________________________________________

Physician Signature: _______________________________ Print Name: ____________________________

Phone: __________________________________________ Date: _________________________________

OVER

Blue Medical Form

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