Mus Pre-Participation Medical History Form - 2016-2017 Page 3
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8** PLEASE PRINT **
EMERGENCY / INSURANCE INFORMATION
201 -1
Student’s Full Name:_________________________________________________
DOB: _____/_____/_____
Age:______
Parent/Guardian _______________________________________
Cell Phone: (
) _____________________________
Names:
(Father, Stepfather, etc..)
_______________________________________
Cell Phone: (
) _____________________________
(Mother, Stepmother, etc..)
Home Address: _________________________________________________________________________________________
Home Phone: (
) _________________________
Father’s Employer:________________________________
Work Phone: (
)___________________________
Mother’s Employer:_______________________________
Work Phone: (
)___________________________
Other Person to Contact: ___________________________ Relationship:________________ Phone: (
)_______________
Insurance Company Name:______________________________________________________________________________
Policyholder Name:_________________________________
Policy/Group Number(s): _____________________________
Known ALLERGIES:_________________________________________________
Wear Contact Lenses:
YES
NO
Current MEDICATIONS:___________________________________________________
******************************************************************************************************
PARENTAL CONSENT TO PARTICIPATE, ACKNOWLEDGMENT OF RISKS & MEDICAL AUTHORIZATION:
I/We hereby give consent for (student’s name) _____________________________________________________ to represent
MEMPHIS UNIVERSITY SCHOOL in the sport(s) of:__________________________________________________________.
FURTHERMORE:
1. I / We hereby acknowledge an awareness that participation in secondary school athletics involves the risk of injury. I/We also
understand that due to the competitive nature of secondary school athletics, injuries may occur which can result in serious p hysical
disability, paralysis, permanent mental disability or even death.
My signature below indicates that I have read and fully understand the potential catastrophic risks associated with participation in
secondary school athletics.
2. Permission is hereby granted to Memphis University School and/or its authorized representatives or medical facility to proceed with any
medical or minor surgical treatment, x-ray, examination or immunization deemed necessary for the well-being of the above-named student. I
/We understand that in the event of a serious or life-threatening injury/illness, the attending physician (or anyone he/she may designate) will
make every attempt to contact us in the most expeditious manner possible. If unable to contact either of us, permission is hereby granted for
treatment or procedure deemed necessary for the well-being of the above named student.
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION: I hereby authorize the MUS medical staff to provide
3.
coaches of MUS with the following information regarding my son: health status, injuries sustained during participation in athletic
events, injury rehabilitation progress, physical limitations, and ability to engage in sports activities. After information is released
to
the coaching staff(s), federal privacy laws no longer protect this information.
4. A photocopy of this sheet shall be considered as effective and valid as the original.
Parent/Guardian Signature:_________________________________________________
Date: _____/_______/______
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