Madison Schools Preparticipation Health Evaluation

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MADISON SCHOOLS
PREPARTICIPATION HEALTH EVALUATION
PERSONAL INFORMATION
Name of Student _____________________________________ Sex_____ Grade Level 2016-17 _____ Age ____ Date of Birth ________________
Street Address: _______________________________City______________________Zip_____________Home Phone: _______________________
Father’s Name: _________________________ Address if different: ________________________________________________________________
Mother’s Name : ________________________ Address if different: ________________________________________________________________
Family Physician: _____________________________________________ Office Phone: _______________________________________________
In case of emergency, parents will be contacted first. Please list a non-parent contact:
Name ___________________________________________________________ Relationship ____________________________________________
Address ___________________________________________________________ Phone (H) ____________________ (W) ____________________
STUDENT PARTICIPATION
**This application to participate in athletics is voluntary on my part and the information submitted is truthful to the best of
my knowledge.
**I have never received money or negotiable certificates for merchandise in any amount, nor any emblematic award or
merchandise worth more than twenty-five dollars ($25.00) for participating in athletic events, nor have I ever competed under
an assumed name. After I have represented my high school in any sport, I will not compete in any outside athletic contest in
this sport until after the high school season has been completed.
**I understand that I am expected to adhere firmly to all established athletic policies of my school district and the Michigan
High School Athletic Association, such as those previously mentioned above as examples but which do not present all the
policies to which I am subject. I consent to the disclosure to the MHSAA of information otherwise protected by FERPA and
HIPPA for the purpose of determining eligibility for interscholastic athletics.
PARENT OR GUARDIAN CONSENT – INJURY WAIVER FORM
**I hereby give my consent for the above student to engage in interscholastic athletics and understand the possibility that
serious injury may result from participating in athletic activities. He/she has my permission to accompany the team as a
member on its out-of-town trips.
**I understand that my son or daughter will be expected to adhere firmly to all established athletic policies of the school
district and the Michigan High School Athletic Association. I consent to the disclosure to the MHSAA of information
otherwise protected by FERPA and HIPPA for the purpose of determining eligibility for interscholastic athletics.
**I agree to reimburse the Athletic Department for equipment/uniforms issued to my son/daughter should it not be returned.
**As the parent or guardian of ____________________________________________________________, in case of
accident or serious illness, I request the school to contact me at this/these number(s) _______________________________
_____________________________________________________________________________________________
**If I cannot be reached I give my authorization to my son/daughter’s athletic coach to sign in lieu of me for any medical
treatment that he/she feels is necessary. Our family physician is ________________________________________________.
**We have our own insurance policy. Yes
No
Name of company __________________________________________.
I hereby state that, to the best of my knowledge, the above information is correct and agree to abide by all conditions stated
above.
X_____________________________________________________
Date _____________________
Signature of Student
X_____________________________________________________
Date:______________________
Signature of Parent or Guardian
**I understand that this entire form will be used for any emergency medical treatment my child might require.
I also understand this entire form may be copied for use by the athletic trainer and/or coaches.
THIS FORM MUST BE ON FILE IN THE HIGH SCHOOL OFFICE BEFORE PRACTICING
WITH ANY ATHLETIC TEAM, PURSUANT TO MHSAA RULES

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