Physical Examination Form

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6145.2 (c)
ARCHDIOCESE OF MILWAUKEE - PHYSICAL EXAMINATION
FORM - ELEMENTARY SCHOOL INTERSCHOLASTIC
ATHLETICS - BOYS AND GIRLS
*Approval for two years of competition. Examination cannot be taken before April 1st.
Student's Name: _____________________________________________________________________
Last
First
Middle Initial
Place of Birth (Cty. St.) ____________________________________________Age:______Sex______
Date of Birth: ______________________Weight:_________________Height:___________________
Grade_______School:__________________________________City:__________________________
The above named student has been examined and there are no apparent restrictions to participating in
interscholastic athletic activities except as follows:
Sports or school activities in which this student cannot participate are (if none - write NONE):
__________________________________________________________________________________
__________________________________________________________________________________
*If approved for only one year of competition, check here. _______
Signature of Licensed Physician or Surgeon: ______________________________________________
(Print or type)
Signature: ________________________________________________________________________
Address: _________________________________________________________________________
City: _______________________________________State:_____________ Zip:________________
Telephone: _______________________________Date of Examination: _______________________
ALL BOYS AND GIRLS PARTICIPATING IN INTERSCHOLASTIC ATHLETICS MUST
HAVE THIS FORM ON FILE AT THEIR SCHOOL/PARISH, PRIOR TO PRACTICE OR
PARTICIPATION.
_________________________________________________________________________________
Form 6145(c)
Archdiocese of Milwaukee
Form revised: 5-6-97
2/15/1995
5/6/1997
5/8/2007

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