Physical Examination Form printable pdf download

ARCHDIOCESE OF MILWAUKEE

Physical Examination Form

Elementary School Interscholastic Athletics – Boys and Girls

Student’s Name: _______________________________________________________________________

Last

Middle Initial

First

Place of Birth (City, State): ___________________________________ 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):

_____________________________________________________________________________________

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

* If approved for only one year of competition, check here: _________

Signature of Licensed Physician or Surgeon: ________________________________________________

Name of Licensed Physician or Surgeon: ___________________________________________________

(print or type)

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 6145.2C

Physical Examination Form

Physical Examination Form