Athletic Participation Form
Name of the Student
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Institute
Grade
Parent/Guardian Name
First Name
Last Name
Parent/Guardian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Athlete Medical History
Physician Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Medical Facility
Please answer the questions accordingly:
Rows
Yes
No
The athlete have any chronic medical illnesses such as diabetes, asthma (exercise asthma), kidney problems, etc.?
1
2
The athlete presently taking any medications or pills?
3
4
The athlete have any allergies?
5
6
The athlete ever had a head injury, been knocked out, or had a concussion?
7
8
The athlete ever had a heat injury or severe muscle cramps with activities?
9
10
The athlete ever passed out or fainted during exercise, emotion or startle?
11
12
The athlete ever had extreme fatigue with exercise?
13
14
The athlete ever had trouble breathing during exercise, or a cough with exercise?
15
16
The athlete ever been diagnosed with exercise-induced asthma ?
17
18
A doctor ever told the athlete that they have high blood pressure?
19
20
A doctor ever told the athlete that they have a heart infection?
21
22
The athlete ever had discomfort, pain, or pressure in his chest during or after exercise or complained of their heart “racing” or “skipping beats”?
23
24
The athlete ever had any problems with their eyes or vision?
25
26
The athlete ever sprained/strained, dislocated, fractured, broken or had repeated swelling or other injury?
27
28
The athlete ever had an eating disorder?
29
30
The athlete ever been hospitalized or had surgery?
31
32
The athlete had a medical problem or injury since their last evaluation?
33
34
If, you have answered as a "Yes" at least one of them, please give details
If you have relevant medical documents please upload here.
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Physical Examination
Height
Weight
Pulse
Date of Examination
-
Month
-
Day
Year
Date
Submit
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