Mckinney Independent School District Uil Physical Exam Form printable pdf download

PHYSICALS MUST BE COMPLETED AFTER APRIL 1, 2014

McKinney Independent School District

UIL Physical Exam Form

Please Print

Student

Name:________________________________________________________________________________________________

Last

First

M.I.

Circle Grade for 20014-15 School year:

7 8 9 10 11

Sport:_____________________________

Student ID#__________________

Sex:____ Age:____ Date of Birth____/____/___ Home Phone:________________

Home Address:___________________________________________________________________________________________

Street

City

State

Zip Code

Parent/Guardian Information:

Mother’s Name:_______________________________________

Father’s Name:__________________________________

Mother's Workplace:___________________________________

Father's Workplace;_____________________________

Work Phone:_________________________________________

Work Phone:__________________________________

Cell Phone:___________________________________________

Cell Phone:____________________________________

E-Mail

Address:_____________________________________________

Address:______________________________________

Emergency Contact:

Name:__________________________________________________

Relationship:___________________________________

Home Phone:____________________________________________

Work Phone:____________________________________

Personal Physician:___________________________________

Phone:__________________________________________

PARENT OR GUARDIAN’S PERMIT

By my signature below, I do hereby acknowledge and agree as follows:



I have been fully informed that participation of the above named student in University Interscholastic League(UIL) approved sports

through McKinney Independent School District(MISD) is strictly voluntary and not required by the MISD. I acknowledge that my

Student’s participation is by his/her own choice and that my Student chooses to at his/her own risk. Further, I hereby give my consent for

my Student to compete in UIL approved sports, and travel with the coach or other representative of the school on any trips.



I understand that even though protective equipment is worn by my Student whenever needed, the possibility of an accident still remains.

Neither the UIL nor the MISD assumes any responsibility in case an accident occurs.



I, the undersigned, agree to be responsible for the safe return of all athletic equipment issued by the school to my Student.



If, in the judgment of any representative of the MISD, my Student needs immediate care and treatment as a result of injury or illness, I do

hereby request, authorize, and consent to such care and treatment as may be given to my Student by any physician, athletic trainer, nurse,

hospital or school representative. I do, individually and on behalf of my Student hereby agree to indemnify hold harmless, release and

discharge the MISD, its governing board, agents, employees, and officers, from any and all claims, demands, liabilities, actions,

judgments, expenses (including attorneys’ fees and costs of defense), and executions which may be made by reason of any injury to my

Student (including, but not limited to, serious bodily injury or death), caused by any act, neglect, default, or omission of any person, firm,

or corporation, directly or indirectly associated with the MISD, arising directly or indirectly out of participation in, or association with

University Interscholastic League approved sports through the MISD.

By my signature below, I hereby give authorization for the MISD, its athletic trainer(s), coach(es), associated physician(s) and student

insurance personnel to share information concerning medical diagnosis and treatment of my student.

Parent/

Guardian Signature:__________________________________________ Date:_____________________

THIS FORM MUST BE ON FILE PRIOR TO ANY PRACTICE, SCRIMMAGE, OFFSEASON PROGRAM, SUMMER CONDTITIONING

PROGRAM, OR CONTEST THAT IS HELD BEFORE, DURING, OR AFTER SCHOOL.

Mckinney Independent School District Uil Physical Exam Form

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