Fillable Sports Qualifying Physical Examination Form - Bedford Public Schools (Page 2 of 4) in pdf

INFORMATION & CONSENT FORM



To be completed by parent/guardian or 18 year old or older student-athlete; please take time to complete

the form to ensure the good health and safety of the student-athlete



Must be signed in four (4) places by parent/guardian or 18 year old or older student-athlete (Below and on page 3)



The exam date must be performed on or after April 15

to be valid for the following school year



Copies of the first two pages, Clearance Form and Information & Consent Form, must be kept on file with school athletic department

Student Name: ______________________________________________________________________________

Last

First

Middle Initial

Sex:______ Grade:________ Age:_______

Date of Birth:_______________

School: ___________________________________ Sport(s): _________________________________________

Student’s Address: ___________________________________________________________________________

Street

City

Zip

Father’s/Guardian Name:_______________________________________________________________________

Phone (home):________________________ (work):__________________ (cell):__________________________

Mother’s/Guardian Name:_______________________________________________________________________

Phone (home):________________________(work): ____________________(cell):_________________________

STUDENT PARTICIPATION & PARENT OR GUARDIAN OR 18 YEAR OLD CONSENT

The information submitted herein is truthful to the best of my knowledge. By my/my child’s signature below, I/we

acknowledge that I/we have received concussion educational information that meets Michigan Department of Health and

Human Services and MHSAA requirements. Further, in consideration of my/my child’s participation in MHSAA-sponsored

athletics, I/we do hereby agree, understand, appreciate, and acknowledge: that participation in such athletics is purely

voluntary; that such activities involve physical exertion and contact and that there is inherent risk of personal injury

associated with participation in such activities, which risk I/we assume; and that I/we agree to, and hereby, waive any and

all claims, suits, losses, actions, or causes of action against the MHSAA, its members, officers, representatives,

committee-members, employees, agents, attorneys, insurers, volunteers, and affiliates based on any injury to me, my child,

or any person, whether because of inherent risk, accident, negligence, or otherwise, during or arising in any way from

my/my child’s participation in an MHSAA-sponsored sport.

I/we understand that I am/we are expected to adhere firmly to all established athletic policies of my school district and the

MHSAA

I/we hereby give my consent for the above student to engage in interscholastic athletics and for the disclosure to the

MHSAA of information otherwise protected by FERPA and HIPAA for the purpose of determining eligibility for

interscholastic athletics. My child has my permission to accompany the team as a member on its out-of-town trips.

Signature of STUDENT: ___________________________________________ Date: __________

____________________________________________________________________

________________

Signature of PARENT OR GUARDIAN OR 18 YEAR-OLD

Date

INSURANCE STATEMENT:

Our son/daughter will comply with the specific insurance regulations of the school district.

The student-athlete has health insurance: Yes

If yes, Family Insurance Co: _____________________________ Insurance ID # __________________________

MEDICAL TREATMENT CONSENT:

I, _______________________________________, an 18 year-old, or 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 OR GUARDIAN OR 18 YEAR-OLD

Date

Sports Qualifying Physical Examination Form - Bedford Public Schools Page 2

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