Wisconsin Interscholastic Athletic Association - Athletic Permit Card printable pdf download

WISCONSIN INTERSCHOLASTIC ATHLETIC ASSOCIATION – ATHLETIC PERMIT CARD

(Print or Type)

ALL STUDENTS PARTICIPATING IN INTERSCHOLASTIC ATHLETICS MUST HAVE THIS CARD ON FILE AT THEIR SCHOOL PRIOR TO PRACTICE OR PARTICIPATION

Physical examination taken April 1 and thereafter is valid for the following two school years; physical examination taken before April 1 is valid only for the remainder of that school

year and the following school year.

NAME (Last) ______________________________________________ (First) ___________________________________ (Middle Initial) _______ Date of Birth _______________

Age ______ Sex ______ Grade _____ School _________________________________________________________ City ____________________________________________

Present Address _____________________________________________________________________________________ Telephone __________________________________

Cleared without restriction

Cleared, with the following qualifications: ___________________________________________________________________

______________________________________________________________________________________________________________________________________________________________

Not cleared

Pending further evaluation

For all sports

For certain sports: ___________________________________________________________

Reason: ______________________________________________________________________________________________________________________________________

Recommendations: _____________________________________________________________________________________________________________________________

I have examined the above-named student and completed the preparticipation physical evaluation. The athlete does not present apparent clinical contraindications

to practice and participate in the sport(s) as outlined above. A copy of the physical exam is on record in my office and can be made available to the school at the

request of the parents. If conditions arise after the athlete has been cleared for participation, a physician may rescind the clearance until the problem is resolved and

the potential consequences are completely explained to the athlete (and parents/guardians).

Name of Physician (Print/Type) _____________________________________________________________________________________________________________________

SIGNATURE OF LICENSED PHYSICIAN (MD OR DO)/APNP*: ___________________________________________________________________________________________

Clinic Name _____________________________________________________________________________________________________________________________________

Address/Clinic _________________________________________________________ City ______________________________________ State _______ Zip Code ___________

Telephone _________________________________________________________________________ Date of Examination ____________________________________________

* Physicians may authorize Nurse Practitioners or Physician Assistants to stamp this card with the physician’s signature or the name of the clinic with which the physician is affiliated.