Student'S Physical Form - Wenatchee High School Athletic Department, Washington Page 2

School   A thletic   E mergency   I nformation/   M edical   C learance  

 

Name   _ ___________________________________________________________________  

Date   o f   B irth   _ ________________________________  

Male____________  

Female______________  

Grade________________  

Age   _ __________________  

Home   A ddress   _ ___________________________________________________     P arent   E -­‐mail   _ ____________________________________________  

Parent/Guardian   _ ______________________________________________________________   C ontact   P hone   #   _ ____________________________  

Parent/Guardian   _ ______________________________________________________________   C ontact   P hone   #   _ ____________________________  

Emergency   C ontact   _ _________________________________   R elationship   _ ___________________   P hone   #   _ ____________________________  

Family   P hysician   _ ________________________________________________________________________   P hone   #   _ ___________________________  

Insurance   C ompany   ( Required)   _ _______________________________   P olicy   N umber   ( Required)   _ __________________________  

(If   y ou   d o   N OT   h ave   f amily   m edical   i nsurance,   y ou   m ust   p urchase   s chool   i nsurance.)  

School   I nsurance:         _ _________   S chool   T ime   P lan  

 

__________   F ull   T ime   P lan  

                _ _______   F ootball   P lan  

In   t he   e vent   o f   s erious   i njury   a nd   y our   f amily   d octor   c annot   b e   c ontacted,   a nd   i f   w e   a re   u nable   t o   c ontact   o ne   o r   t he   o ther   p arent/guardian,    

does   t he   c oaching   s taff/athletic   t rainer   h ave   y our   p ermission   t o   s eek   m edical   a ttention   f rom   t he   n earest   p hysician?  

_______   Y ES     _ ______   N O      

 

If   y our   a nswer   i s   N O,   p lease   s tate   p rocedure   y ou   w ish   t he   c oaching   s taff/athletic   t rainer   t o   f ollow:

_________________________________________________________________________________________________________________________  

 

I   a uthorize   r elease   o f   t he   h ealth   c are   p ractitioner’s   ( family   p hysician   a nd/or   a thletic   p hysical   p rovider)   e xam   f indings   a nd   o ther   p ertinent   m edical  

data   a s   i t   r elates   t o   t he   p articipation   o f   m y   c hild   i n   W enatchee   S chool   D istrict   s ports   a ctivites.     I   u nderstand   t hat   t he   p hysical   e xam   d ocumentation  

will   b e   k ept   o n   f ile   a t   t heir   s chool   f or   m iddle   l evel   a thletes   a nd   i n   t he   W enatchee   H igh   S chool   A thletic   D epartment   f or   h igh   s chool   a thletes.  

 

____________________________________________________________________    

____________________________________________  

Parent/Guardian   S ignature  

 

 

 

 

 

Date  

 

FALSIFYING   S IGNATURES   O N   A NY   R EQUIRED   F ORM   W ILL   B E   C AUSE   F OR   L OSS   O F   E LIGIBILITY   F OR   A CTIVITY  

 

PHYSICAL   E XAMINATION   –   P rior   t o   t he   f irst   p ractice   f or   p articipation   i n   i nterscholastic   a thletics,   a   s tudent   s hall   u ndergo   a  

thorough   m edical   e xamination   a nd   b e   a pproved   f or   i nterscholastic   a thletic   c ompetition   b y   a   m edical   a uthority   l icensed   t o  

perform   a   p hysical   e xamination.  

 

Are   t here   s ignificant   f indings   t he   s chool   m edical/coaching   s taff   s hould   b e   a ware   o f:  

________  

Head/neck/spine/injuries    

 

________  Loss   o f   p aired   o rgans  

________  

Musculoskeletal   i njuries  

 

 

________  Medications  

________  

Cardiopulmonary   c onditions  

 

________  Allergic   t o   m edicines/insect   b ites/other  

________  

Other   m edical   c onditions   ( describe)  

 

Please   e xplain   a ny   o f   t he   a bove:   _ ___________________________________________________________________________________  

 

ASSESSMENT:  

________  

Full   P articipation  

________  

Limited   P articipation   ( describe   l imitations.   r estrictions):   _ __________________________________________  

________  

Participation   C ontraindicated   ( list   r easons   a nd   s ports):   _ ____________________________________________  

Recommendations   ( equipment,   b racing,   t aping,   r ehabilitation,   e tc):   _ __________________________________________  

 

Those   l icensed   t o   p erform   p hysical   e xaminations   i nclude   a   M edical   D octor   ( MD),   D octor   o f   O steopathy   ( DO),   A dvanced  

Registered   N urse   P ractitioner   ( ARNP),   P hysician’s   A ssistant   ( PA)   a nd   N aturopathic   P hysician.  

 

___________________________    

 

 

____________________________________________________________________

 

Date   o f   P hysical   E xam    

 

 

Examiner’s   S ignature  

 

____________________________________________________________________  

Examiner’s   N ame   ( Print)