WAUWATOSA SCHOOL DISTRICT                            Sport______________

HIGH SCHOOL ATHLETIC PARTICIPATION FORM – PHYSICAL

All athletes participating in WIAA Interscholastic Athletics must have this sheet on file at the school prior to practice or participation.

 

PHYSICAL EXAMINATIONS taken April 1 or after are valid for the following two school years.  If taken

          before April 1 they are valid only for the remainder of that school year and the following school year.

 

 

__________________________________________________        __________________

Last Name                          First Name               Initial                        Date of Birth

 

________________________________________           __________       ____     _______

Place of Birth (County and State)                                      Grade                 Age       Sex

 

Parents’ Place of Employment ________________________________________________

 

Family Physician______________________    Family Dentist_______________________

 

To be completed by physician:

 

                 The above named student has been examined and there is no contraindication to participating in interscholastic athletic activities except as follows: 

                  (Physicians note:  Please refer to the guide for athletic disqualifications.)_________________________________________________________

If student is restricted or disqualified from any sports or school activities, please indicate.  (if none, write

“none”.)___________________________________________________________________

If student requires an annual physical (rather than the WIAA requirement of a physical every 2 years), please indicate

here_______________________________________________________

 

Signature of licensed physician or surgeon ______________________________________

Address________________________________ City and State______________________

Telephone ________________________ Date of exam____________________________

 

I attest to the fact that the information given above is accurate and correct.

Parent Signature                                                                                                   Date                          

 

THIS SHEET IS TO BE COMPLETED AND RETURNED TO THE ATHLETIC DEPARTMENT