To be completed by parent or guardian or 18-year-old.
Must be signed below by parent or guardian or 18-year-old.
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.
To be completed by parent or guardian or 18-year-old.
Must be signed in two places on this page by parent or guardian or 18-year-old.
Appearance: Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency)
Eyes/Ears/Nose/Throat: Pupils Equal Hearing
Lymph Nodes
Heart: Murmurs (auscultation standing, supine, +/- Valsalva) Location of point of maximal impulse (PMI)
Pulses: Simultaneous femoral and radial pulses
Lungs
Abdomen
Skin
Genitourinary (Males Only)
HSV,
lesions suggestive of MRSA, tinea corporis
Neck
Back
Shoulder / Arm
Elbow / Forearm
Wrist / Hand / Fingers
Hip / Thigh
Knee
Leg / Ankle
Foot / Toes
Foot / Toes
Functional: Duck Walk
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
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
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.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
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.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Your information will be encrypted.