View as a PDF 7-8 Grade Physical Form

School Year 20___ - 20__

ATHLETIC PERMIT     STUDENT NAME _______________________________________________ DATE OF BIRTH _______   PRESENT ADDRESS ___________________________________________ TELEPHONE __________________________   FAMILY PHYSICIAN ____________________________________   NAME OF PRIVATE INSURANCE CARRIER(S) _____________________________________________________________   POLICY NUMBER(S) __________________________________________________________________________________   I as parent (or legal guardian) of the above named student hereby give my permission for the above named student to practice and compete and represent St. Pauls in interscholastic sports excepting those restricted on this card. I agree to be financially responsible for the safe return of all athletic equipment issued to him/her. I further grant permission for my son/daughter, named above, to be given immediate emergency care in case of injury as a result of athletic competition. I also grant permission for any medical records pertaining to the health of the above named student to be made available as necessary to the proper school or medical personnel.         _______________________________________________ Date _________________ (Signature of Parent of Legal Guardian)

PHYSICAL EXAMINATION   NOTE: Examination taken on or after APRIL 1st is good for the following TWO SCHOOL YEARS. Examination taken before APRIL 1 is good for the remainder of that SCHOOL YEAR and the FOLLOWING SCHOOL YEAR.   NAME ________________________________ SEX ____ HEIGHT_____ WEIGHT ______ AGE _____ GRADE ______   SCHOOL _____________________________________________ CITY _____________________________   The above named student has been examined and there are no apparent contraindications 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 student is restricted or disqualified, please indicate reason(s):_________________________________________________   If approved for only one year of competition, check here [ ]   Signature of Licensed Physician or Surgeon ________________________________________________________________   Phone _________________ Date of Exam _______________________________________     ALL 7-8 GRADE STUDENTS PARTICIPATING IN INTERSCHOASTIC ATHLETICS MUST HAVE THIS FORM ON FILE