Mhsaa Medical Form PDF Details

For any high school student or parent, ensuring their eligibility as an athlete and maintaining a healthy lifestyle is incredibly important. The Michigan High School Athletic Association (MHSAA) requires all athletes to complete the appropriate medical forms in order to remain eligible for postseason competition. Completion of the correct form(s), including a physical exam form, consent and release from liability forms, and parental/guardian consent forms are highly important steps when it comes to surrounding your health and safety with ample care. In this blog post, we will teach you about the different MHSAA medical form requirement processes as well as explain where you can access these documents online.

QuestionAnswer
Form NameMhsaa Medical Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namessports physical form michigan form, michigan sports physical form, mhsaa physical form 2021, michigan sports physical form 2021

Form Preview Example

MICHIGAN HIGH SCHOOL ATHLETIC ASSOCIATION, INC.

 

 

 

 

 

 

 

 

 

 

 

 

MEDICAL HISTORY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

• To

e

o pleted

y pare t or guardia

or 18-year-old.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

• Must

 

e sig ed below 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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LAST

 

 

 

 

 

 

 

 

 

 

FIRST

 

 

 

MI

 

 

SEX

GRADE

 

DATE OF BIRTH

 

AGE

 

STUDENT’S NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

---

---

 

 

 

 

 

 

 

 

 

 

 

NUMBER AND STREET

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

 

 

 

 

ZIP

 

STUDENT’S ADDRESS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF FATHER OR GUARDIAN

 

 

 

 

 

 

 

WORK PHONE

 

NAME OF MOTHER OR GUARDIAN

 

 

 

 

 

 

 

 

WORK PHONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FAMILY DOCTOR

 

 

 

 

 

 

 

 

 

OFFICE PHONE

 

STUDENT’S HOME PHONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICAL HISTORY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GENERAL QUESTIONS

 

 

 

YES

 

 

NO

 

 

YOUR FAMILY’S

HEART HEALTH QUESTIONS

 

 

 

YES

 

 

NO

 

 

 

MEDICAL QUESTIONS

 

 

 

 

YES

 

 

NO

 

 

 

Has a Doctor ever denied or restricted your participation in

 

 

 

 

 

 

 

Does anyone in your family have arrhythmogenic

 

 

 

 

 

 

 

 

Do you have any concerns that you would like to

 

 

 

 

 

 

 

 

Sports for any reason?

 

 

 

 

 

 

 

 

 

right ventricular cardiomyopathy, long QT syndrome?

 

 

 

 

 

 

 

 

discuss with a doctor?

 

 

 

 

 

 

 

 

 

 

 

Do you have any ongoing medical conditions? If so, please

 

 

 

 

 

 

 

Has any family member or relative died of heart

 

 

 

 

 

 

 

 

Were you born without or are you missing an organ?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Problems or had an unexpected or unexplained sudden

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Identify by Circling: Asthma

Anemia Diabetes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Identify by circling: A kidney An eye

Your spleen

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

death before age 50 (including drowning, unexplained

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Infections

Other: ________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A testicle (males)

Any other organ? _____________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

car accident or sudden infant death syndrome) ?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you ever spent the night in the hospital?

 

 

 

 

 

 

 

Does anyone in your family have catecholaminergic

 

 

 

 

 

 

 

 

Have you ever had an eating disorder?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

polymorphic ventricular tachycardia, short QT syndrome?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you ever had surgery?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you worry about your weight?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HEART HEALTH QUESTIONS ABOUT YOU

 

 

YES

 

 

NO

 

 

BONE AND JOINT QUESTIONS

 

 

 

YES

 

 

NO

 

Have you ever had a head injury or concussion?

 

 

 

 

 

 

 

 

Have you ever passed out or nearly passed out DURING

 

 

 

 

 

 

 

Have you ever had an injury to a bone, muscle, ligament

 

 

 

 

 

 

 

 

Have you ever had a hit or blow to the head that caused

 

 

 

 

 

 

 

 

or after exercise?

 

 

 

 

 

 

 

 

 

or tendon that caused you to miss a practice or a game?

 

 

 

 

 

 

 

 

confusion, prolonged headache, or memory problems?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you ever had discomfort, pain, tightness or pressure

 

 

 

 

 

 

 

Have you ever had any broken or fractured bones or

 

 

 

 

 

 

 

 

Have you ever had numbness, tingling, or weakness in

 

 

 

 

 

 

 

 

in your chest during exercise?

 

 

 

 

 

 

 

 

 

dislocated joints?

 

 

 

 

 

 

 

 

 

 

 

 

your arms or legs after being hit or falling?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you get lightheaded or feel more short of breath than

 

 

 

 

 

 

 

Have you ever had an injury that required x-rays, MRI,

 

 

 

 

 

 

 

 

Have you ever been unable to move your arms or legs

 

 

 

 

 

 

 

 

expected during exercise?

 

 

 

 

 

 

 

 

 

CT scan, injections, therapy, a brace or cast or crutches?

 

 

 

 

 

 

 

 

after being hit or falling?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you get more tired or short of breath more quickly than

 

 

 

 

 

 

 

Have you ever been told that you have neck instability or

 

 

 

 

 

 

 

 

Are you trying to or has anyone recommended that you

 

 

 

 

 

 

 

 

your friends during exercise?

 

 

 

 

 

 

 

 

 

atlantoaxial instability (Down syndrome or dwarfism)?

 

 

 

 

 

 

 

 

gain or lose weight?

 

 

 

 

 

 

 

 

 

 

 

 

Has a doctor ever ordered a test for your heart?

 

 

 

 

 

 

 

Have you ever had an x-ray for neck instability or

 

 

 

 

 

 

 

 

Are you on a special diet or do you avoid certain

 

 

 

 

 

 

 

 

For example: ECG/EKG, echocardiogram

 

 

 

 

 

 

 

atlantoaxial instability (Down syndrome or dwarfism)?

 

 

 

 

 

 

 

 

types of foods?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you ever had an unexplained seizure or do you have

 

 

 

 

 

 

 

Do you regularly use a brace, orthotics, or other assistive

 

 

 

 

 

 

 

 

Do you wear protective eyewear, such as goggles, or a

 

 

 

 

 

 

 

 

a history of seizure disorder?

 

 

 

 

 

 

 

 

 

device?

 

 

 

 

 

 

 

 

 

 

 

 

face shield?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does your heart ever race or skip beats (irregular beat)

 

 

 

 

 

 

 

Do any of your joints become painful, swollen, feel warm

 

 

 

 

 

 

 

 

Do you or someone in your family have sickle cell trait

 

 

 

 

 

 

 

 

during exercise?

 

 

 

 

 

 

 

 

 

or look red?

 

 

 

 

 

 

 

 

 

 

 

 

or disease?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has a doctor ever told you that you have high blood

 

 

 

 

 

 

 

Do you have any history of juvenile arthritis or

 

 

 

 

 

 

 

 

Have you had any problems with your eyes or vision

 

 

 

 

 

 

 

 

pressure?

 

 

 

 

 

 

 

 

 

connective tissue disease?

 

 

 

 

 

 

 

 

or had any eye injuries?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has a doctor ever told you that you have high cholesterol?

 

 

 

 

 

 

 

Have you ever had a stress fracture?

 

 

 

 

 

 

 

 

Do you wear glasses or contact lenses?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has a doctor ever told you that you have Kawasaki disease?

 

 

 

 

 

 

 

Have you a bone, muscle, or joint injury bothering you?

 

 

 

 

 

 

 

 

Have you ever had herpes or MRSA skin infection?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has a doctor ever told you that you have other heart

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you had infectious mononucleosis (mono) within

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IMMUNIZATION HISTORY

 

 

 

YES

 

 

NO

 

 

 

 

 

 

 

 

 

 

problems?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

the last month?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has a doctor ever told you that you have a heart infection?

 

 

 

 

 

 

 

Are you missing any recommended vaccines (Tdap, Flu,

 

 

 

 

 

 

 

 

Do you have any rashes, pressure sores, or other skin

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MCV4, HPV, Varicella, MMR)

 

 

 

 

 

 

 

 

problems?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has a doctor ever told you that you have a heart murmur?

 

 

 

 

 

 

 

MEDICAL QUESTIONS

 

 

 

YES

 

 

NO

 

Do You Have Any Allergies?

 

 

 

 

 

 

 

 

 

 

 

YOUR FAMILY’S HEART HEALTH QUESTIONS

 

 

YES

 

 

NO

 

Have you ever become ill while exercising in the heat?

 

 

 

 

 

 

 

 

 

FEMALES ONLY

 

 

 

 

YES

 

 

NO

 

 

 

Does anyone in your family have a heart problem,

 

 

 

 

 

 

 

Do you cough, wheeze, or have difficulty breathing

 

 

 

 

 

 

 

 

Have you ever had a menstrual period?

 

 

 

 

 

 

 

 

 

 

 

Pacemaker, or implanted defibrillator?

 

 

 

 

 

 

 

during or after exercise?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does anyone in your family have hypertrophic

 

 

 

 

 

 

 

Do you have headaches or get frequent muscle cramps

 

 

 

 

 

 

 

 

How old were you when you had your first

 

 

 

 

 

 

 

 

cardiomyopathy, Marfan syndrome, Brugada syndrome?

 

 

 

 

 

 

 

When exercising?

 

 

 

 

 

 

 

 

 

 

 

 

menstrual period?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Anyone in your family had unexplained fainting?

 

 

 

 

 

 

 

Do you have pain,

a painful bulge or hernia in the groin?

 

 

 

 

 

 

 

 

How many periods have you had in the last

 

 

 

 

 

 

 

 

Anyone in your family had unexplained seizures?

 

 

 

 

 

 

 

Is there any one in your family who has asthma?

 

 

 

 

 

 

 

 

twelve (12) months?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Anyone in your family had unexplained near drowning?

 

 

 

 

 

 

 

Have you ever used an inhaler or taken asthma medicine?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSURANCE STATEMENT AND CERTIFICATION

Our Son/Daughter will comply with the specific insurance regulations of the school district and the Medical History questions are as complete and correct as possible.

Family Insurance Co: ________________________________________________ Contract #: _______________________________________

Signatures of Student: ___________________________ & Parent/Guardian or 18 Year Old: ____________________________________

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

EMERGENCY INFORMATION – To Be Completed by Parent or Guardian or 18 Year Old

Stude t’s Na e: ____________________________________________________________________________ Grade: _______

IN EMERGENCY

1) _________________________________ Phone #: ___________________ Cell #: ____________________

CONTACT

or 2) _______________________________ Phone #: ___________________ Cell #: ____________________

Family Doctor: ______________________________________________________________ Phone: ______________________

Allergies: _____________________________________________________________________________________

Drug Reactions: _____________________________________________________________________________________

Current Medications: _____________________________________________________________________________________

MICHIGAN HIGH SCHOOL ATHLETIC ASSOCIATION, INC.

 

 

 

 

PHYSICAL EXAM & CLEARANCE & CONSENT FORMS

 

 

 

 

 

 

 

 

• To

e

o pleted

y pare

t or guardia or 18-year-old.

 

 

 

 

 

 

 

• Must

e sig ed i

TWO 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: 7

8 9 10

11 12

 

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: (Circle Correct Response As Necessary)

Height:

Weight:

Male/Female

BP:

/

Pulse:

 

Vision: R 20/

 

L 20/

Corrected: Yes No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

EXAMINER: _______________________________________________________________________________________________________ MD

DO PA NP

 

 

PRINTED NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OF EXAMINER: ____________________________________________________________________________________________ DATE: _______________________

 

STUDENT PARTICIPATION & PARENT OR GUARDIAN OR 18 YEAR OLD CONSENT

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.

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 STUDENT: _______________________________________________________________________ Date: ________________

Signature of PARENT: _______________________________________________________________________ Date: ________________

or GUARDIAN or 18 YEAR-OLD

------------------------------- < 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

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