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