Northside Prep Athletics Northwestern University Feinberg School Of Medicine Physical Consent Form
ADVERTISEMENT
1Northside Prep Athletics
Northwestern University Feinberg School of Medicine
Physical Consent Form
Parental Consent for Sports Physical & Child’s Information
_________________________________________
Child’s Name
_________________
Home Phone Number
_________________________________________
Home Address
_________________
Zip Code
____________________
_____________
City
State
_________________
Phone Number
_________________________________________________
Parental/Guardian Contact
_________________
Date of Birth
Caregiver Information
Northwestern University Feinberg School of Medicine
303 East Chicago Avenue
Chicago Il 60611-3008
312-503-8649
I, ____________________________________ give consent to the Northwestern
Parent/Guardian Name
University Feinberg School of Medicine to provide a complete sports medical
examination to my child __________________________ during my absence.
Athlete’s Name
I understand this will take place at Northside College Prep H.S. on Monday August
25, 2013.
___________________________________________
______________
Parental/Guardian Authorizing Signature
Date
Please fill this form out if you will be receiving a physical exam without a parent present on Monday AUGUST 12,
2013.
NOTE: in order to make an appointment to have a physical exam at Northside on Monday AUGUST 12, 2013 students must have
their parents fill out and sign the medical history portion of the IHSA physical form as well as submit a completed waiver form. The
forms should be turned in or emailed to Andrew Mayer (NCP Athletic Director) at AMayer@cps.edu, at which time an appointment
will be made for Monday AUGUST 12, 2013. Appointments begin at 6:30pm. There is a suggested donation of $25.00 which will go
towards having a full time athletic trainer at Northside this year. Checks can be made payable to Northside Prep.
ADVERTISEMENT
0 votes
Related Articles
Related forms
![School Participation List [spl] & Consent Form - National Genius Search Examination - 2018](https://data.formsbank.com/pdf_docs_html/310/3105/310513/page_1_thumb.png "School Participation List [spl] & Consent Form - National Genius Search Examination - 2018")
![School Participation List [spl] & Consent Form - National Genius Search Examination - 2018](https://data.formsbank.com/pdf_docs_html/310/3105/310515/page_1_thumb.png "School Participation List [spl] & Consent Form - National Genius Search Examination - 2018")
Va Form 10-0094a - Medical Education Affiliation Agreement Between Department Of Veterans Affairs (va), And Institutions Sponsoring Graduate Medical Education And Their Affiliated School Of Medicine
Legal
Related Categories
Parent category: Medical