Medical History Form - Michigan High School Athletic Association (Page 2 of 2) in pdf

PRE-PARTICIPATION PHYSICAL - CONSENT - INSURANCE

Shaded headline areas are to be completed by student, parent/guardian or 18-year-old

There are FOUR (4) signatures on this page

to be completed by student, parent/guardian and/or 18-year-old

A CURRENT-YEAR PHYSICAL IS ONE GIVEN ON OR AFTER APRIL 15 OF THE PREVIOUS SCHOOL YEAR

michigan high school

athletic association

Student Name: _________________________________________________________________________________________________________________

last

first

middle initial

Student Address: _______________________________________________________________________________________________________________

street

city

zip

Gender:

Age: _____ Date of Birth: _____________________ Place of Birth (City/State): ________________________________________

School: _________________________________________________________________________ Circle Grade:

Father/Guardian Name: __________________________________________________________________________________________________________

Phone (home): _________________________________ (work): _______________________________ (cell): ______________________________________

Mother/Guardian Name:__________________________________________________________________________________________________________

Phone (home): _________________________________ (work): _______________________________ (cell): ______________________________________

Email Address: Parent/Guardian/18-Year-Old:__________________________________________________________________________________________

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 #: __________________________________________

Additionally, I hereby state that, to the best of my knowledge, my answers to the medical history questions (see reverse) are complete and correct.

Signature of PARENT or GUARDIAN or 18-YEAR-OLD: ___________________________________________________ Date: __________________

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - (DETACH HERE IF NEEDED TO ACCOMPANY STUDENT-ATHLETE) - - - - - - - - - - - - - - - - - - - - - - - - - - - -

MEDICAL TREATMENT CONSENT: COMPLETED BY PARENT or GUARDIAN or 18-YEAR-OLD

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: __________________