Michigan High School Athletic Association Medical History, Physical Exam & Clearance & Consent Forms (Page 2 of 2) in pdf

MICHIGAN HIGH SCHOOL ATHLETIC ASSOCIATION, INC.

PHYSICAL EXAM & CLEARANCE & CONSENT FORMS

• To be completed by parent or guardian or 18-year-old.

• Must be signed in three places on this page by parent or guardian or 18-year-old.

A CURRENT-YEAR PHYSICAL IS ONE GIVEN ON OR AFTER APRIL 15 OF THE PREVIOUS SCHOOL YEAR

PLEASE PRINT

Last

First

Middle

STUDENT’S COMPLETE

LEGAL NAME:

STUDENT’S

Month

Day

Year

PLACE

City

State

│

DATE OF BIRTH:

OF BIRTH:

CIRCLE GRADE:

SCHOOL:

PHYSICAL EXAMINATION & MEDICAL CLEARANCE

To be completed by the examining MD, DO, PA or NP & Returned Directly to the patient. Categories may be added or deleted. Check Appropriate Column

EXAMINATION:

Height:

Weight:

Male/Female

BP:

Pulse:

Vision: R 20/

L 20/

Corrected: Yes No

(Circle Correct Response As Necessary)

MEDICAL

NORMAL

ABNORMAL FINDINGS

MUSCULOSKELETAL

NORMAL

ABNORMAL FINDINGS

Appearance: Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly,

Neck

arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency)

Back

Eyes/Ears/Nose/Throat:

Pupils Equal

Hearing

Shoulder/Arm

Lymph Nodes

Elbow/Forearm

Heart: Murmurs (auscultation standing, supine, +/- Valsalva) Location of point of maximal impulse (PMI)

Wrist/Hand/Fingers

Pulses:

Simultaneous femoral and radial pulses

Hip/Thigh

Lungs:

Knee

Abdomen

Leg/Ankle

Genitourinary (Males Only)

Foot/Toes

Skin:

HSV,

lesions suggestive of MRSA, tinea corporis

Functional: Duck Walk

Neurologic:

RECOMMENDATIONS: ____________________________________________________________________________________________________________________________________________________________________

I certify that I have examined the above student and recommend him/her as being able to compete in supervised athletic activities NOT crossed out below

BASEBALL - BASKETBALL - BOWLING - COMPETITIVE CHEER - CROSS COUNTRY - FOOTBALL - GOLF - GYMNASTICS

ICE HOCKEY - LACROSSE - SKIING - SOCCER - SOFTBALL - SWIMMING - TENNIS - TRACK & FIELD - VOLLEYBALL - WRESTLING

A CURRENT-YEAR PHYSICAL IS ONE GIVEN ON OR AFTER APRIL 15 OF THE PREVIOUS SCHOOL YEAR

SIGNATURE OF

CIRCLE ONE

DO PA

EXAMINER: _______________________________________________________________________________________________________

PRINTED NAME

OF EXAMINER: ____________________________________________________________________________________________ DATE: _______________________

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 certificate 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 school in any sport, I will not compete in any outside athletic contest in this sport

until after my 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.

Signature of STUDENT: _____________________________________________________________________________ Date: __________________

PARENT OR GUARDIAN OR 18 –YEAR-OLD CONSENT

I hereby give my consent for the above student to engage in interscholastic athletics and for the disclosure to the MHSAA of information otherwise protected by FERPA and

HIPAA for the purpose of determining eligibility for interscholastic athletics; and I 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 further 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.

__________________________________________________________________________________________ _____________________

Signature of PARENT OR GUARDIAN OR 18 YEAR-OLD

Date

------------------------------- < DETACH HERE IF NEEDED TO ACCOMPANY STUDENT ATHLETE > ------------------------------------

MEDICAL TREATMENT CONSENT – To Be Completed By Parent or Guardian or 18-Year-Old

I, ________________________________________, an 18 year-old, or the parent or guardian of ________________________________ recognize

that as a result of athletic participation, medical treatment on an emergency basis may be necessary, and further recognize that school personnel

may be unable to contact me for my consent for emergency medical care. I do hereby consent in advance to such emergency care, including

hospital care, as may be deemed necessary under the then-existing circumstances and to assume the expenses of such care.

______________________________________________________________________________________ ________________

SIGNATURE OF PARENT OR GUARDIAN OR 18 YEAR-OLD

DATE

Michigan High School Athletic Association Medical History, Physical Exam & Clearance & Consent Forms Page 2

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