Physical Examination Form printable pdf download

Form

6145.2 (c)

ARCHDIOCESE OF MILWAUKEE - PHYSICAL EXAMINATION

FORM - ELEMENTARY SCHOOL INTERSCHOLASTIC

ATHLETICS - BOYS AND GIRLS

*Approval for two years of competition. Examination cannot be taken before April 1st.

Student's Name: _____________________________________________________________________

Last

First

Middle Initial

Place of Birth (Cty. St.) ____________________________________________Age:______Sex______

Date of Birth: ______________________Weight:_________________Height:___________________

Grade_______School:__________________________________City:__________________________

The above named student has been examined and there are no apparent restrictions to participating in

interscholastic athletic activities except as follows:

Sports or school activities in which this student cannot participate are (if none - write NONE):

__________________________________________________________________________________

*If approved for only one year of competition, check here. _______

Signature of Licensed Physician or Surgeon: ______________________________________________

(Print or type)

Signature: ________________________________________________________________________

Address: _________________________________________________________________________

City: _______________________________________State:_____________ Zip:________________

Telephone: _______________________________Date of Examination: _______________________

ALL BOYS AND GIRLS PARTICIPATING IN INTERSCHOLASTIC ATHLETICS MUST

HAVE THIS FORM ON FILE AT THEIR SCHOOL/PARISH, PRIOR TO PRACTICE OR

PARTICIPATION.

_________________________________________________________________________________

Form 6145(c)

Archdiocese of Milwaukee

Form revised: 5-6-97

2/15/1995

5/6/1997

5/8/2007

Physical Examination Form