WOODLAND MIDDLE SCHOOL ATHLETICS MEDICAL FORM

 

PHYSICIAN’S CERTIFICATE

I hereby certify that (Student’s Name)                                                                         has
been examined by me and found to be physically fit to engage in all school athletics.

 

Remarks:                                                                                                                                   

 

Date:                                   Physician’s Signature:                                                                

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                    *** Entire Form Must Be Completed for Athletic Eligibility ***

EMERGENCY TREATMENT

To All parents:

Since the malpractice question has come to the forefront, many hospitals and doctors
will not treat a child without a parent(s) consent (unless a matter of life or death).  It is
requested that you complete the information below so that if your child requires a visit
to the hospital while under the Supervision of the school, this will allow the hospital to
treat the injury.

 

EMERGENCY INFORMATION

Name:                                        Sport(s):                                    Sex (Please Circle):  M       F

Grade:                                   Age:                                        Date of Birth:           /           /          

Parent(s) Name(s):                                                                                                                        

Father’s SS#:                                                  Mother’s SS#:                                                      

Work Address:                                                                                                                               

Work Phone Number(s):                                                                                                             

Home Address:                                                                                                                             

Home Phone Number:                                        Cell Number(s):                                              

Another Person to Contact:                                                  Relationship:                               

Insurance Name:                                                                                                                           

Policy and Group Number(s):                                                                                                      

ALLERGIES:                                                                                                                                   

Consent Statement:  Authorizing Treatment

Parent(s)

Signature:                                                                                                                                       

PARENT(S) CONSENT

I hereby give my consent for (student’s name)                                                                         
to represent (name of school)           Woodland Middle School              in the sport(s) of:

                                                                                                                                                         

 

Date:                                                  Signature: