MISSISSIPPI ATHLETIC PARTICIPATION FORM

ATHLETIC HEALTH HISTORY

Please correct the errors described below.

ATHLETIC HEALTH HISTORY

FAMILY MEDICAL HISTORY

Has any member of your family under age 50 had these conditions?

ATHLETE'S ORTHOPAEDIC HISTORY

Has the athlete had any of the following injuries?

ATHLETE'S MEDICAL HISTORY

Has the athlete had any of these conditions?

To the best of our knowledge, we have given true and accurate information and we hereby grant permission for the physical screening evaluation. We understand the evaluation involves a limited examination and the screening is not intended to nor will it prevent injury or sudden death. We further understand that the examination will be provided without expectation of payment and that the physician and many other medical professionals providing services may be immune from liability under Mississippi law.

WAIVER FORM

This waiver, executed by given date above by physician and patient, is executed in compliance with Mississippi law, with the full understanding that if a physician voluntarily provides needed medical or health services to any program at an accredited school in the state without expectation of payment, the physician will be immune from liability for any civil action arising out of the provision of those medical and/or health care services which were provided in good faith on a charitable basis. Such immunity does not extend to willful acts or gross negligence.

Patient's Parent or Guardian (If Patient is 17 or younger)

Information below to be filled out by physician only

Orthopaedic Exam

I. Spine / Neck:

Cervical:

Thoracic:

Lumbar:

II. Upper Extremity:

Shoulder:

Elbow:

Wrist:

Hand / Fingers:

III. Lower Extremity:

Hip:

Knee:

Ankle:

Feet:

General Medical Exam

ENT:

Heart:

Skin:

Lungs:

Abdomen:

Hernia (if Needed):

FLEXIBILITY

Neck:

Hips:

Hams:

Back Ext / Flex:

Shoulder:

Quads:

Heelcords:

OPTIONAL EXAMS

VISION

PHYSICIAN - WHITE SCHOOL - CANARY PARENT/GUARDIAN - PINK

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