MICHIGAN HIGH SCHOOL ATHLETIC ASSOCIATION, INC.
MEDICAL HISTORY
(*TO BE COMPLETED BY PARENTS - MUST BE SIGNED IN 3 PLACES)
PLEASE PRINT

NAME:___________________________________ GRADE:_________ AGE:_______ SEX:__________
                           LAST                                     FIRST

ADDRESS:___________________________________________________________
                            STREET                                                                         CITY                                       ZIP CODE

FATHER'S NAME:____________________________   WORK PHONE:_______________

MOTHER'S NAME:___________________________________  WORK PHONE:___________________

HOME PHONE:______________________________________  DATE OF BIRTH:__________________

FAMILY DOCTOR:____________________________________ OFFICE PHONE:_________________

PHYSICAL EXAMINATION - CATEGORIES MAY BE ADDED OR DELETED
(TO BE COMPLETED BY PHYSICIAN - CHECK APPROPRIATE COLUMN)

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 -VOLLEYBALL - WRESTLING
A current year physical is one given on or after April 15th of the previous school year.

DATE:__________________ Signature of Examining Physician:______________________________________ MD___ DO___ PA___ NP___

PRINTED NAME OF EXAMINER:___________________________________________________________________________________________

MEDICAL TREATMENT CONSENT
(TO BE COMPLETED BY PARENTS)

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.

DATE:________________*SIGNATURE OF PARENT/GUARDIAN/18 YEAR-OLD________________________________________________

STUDENT AND PARENT CONSENT FORM
PLEASE PRINT

COMPLETE LEGAL NAME:_____________________________________________
                                                                              LAST                                      FIRST                                      MIDDLE

DATE OF BIRTH:_________________________PLACE OF BIRTH___________________________
                          MONTH         DAY          YEAR                                                  CITY                             STATE

GRADE:________________SCHOOL:__________________________________________________

STUDENT PARTICIPATION

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 merchandise in any amount, or any emblematic award worth more than twenty-five dollars ($25.00) for participation in athletic events, nor have I ever competed under an assumed name.  After I have represented my high school in any sport, I promise not to compete in any outside athletic contest in this sport until after the high 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.

DATE:__________________SIGNATURE OF STUDENT________________________________________

PARENT OR GUARDIAN CONSENT

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 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.

DATE:_________________*SIGNATURE OF PARENT/GUARDIAN/18 YEAR-OLD________________________________________________

FORM A-200M-93