2018-2019 SCHOOL YEAR
Sports Physical Clearance Checklist
Please read and sign all forms

___ P 1. Checklist page.
____P 2.  Physical Evaluation Form -- must only be done by MD, DO, PNP ( No Chiropractors).

 BE SURE to mark clearance or not.
 EXAMINATION date needs to be within a year.
 REQUIRED Doctor’s office stamp.

____P 3. Health History form-- complete and MAKE SURE it’s signed by parent/guardian & athlete.
____P 4/5  Complete #1 Emergency and insurance information form & student insurance
verification letter (For Athletic Director).
**** Please attach one copy of current insurance card ***
____P 6/7. Complete #2 Emergency and insurance information form & student insurance
verification letter (For coach).

**** Please attach one copy of current insurance card ***
____ P 8. Athlete code of Ethics-- Read and sign by athlete and parent/guardian.
____ P 9. Parent/Guardian Code of Ethics -- Read and sign by parent/guardian.
____ P 10. Waiver of liability and release -- read and sign by parent/guardian and athlete.
____P 11. Sudden Cardiac Arrest information Sheet—read and sign by parent/guardian and athlete.
____ P 12/13. Concussion Information Sheet-- read and sign by parent/guardian and athlete.

PLEASE RETURN ALL COMPLETED FORMS TO THE HEALTH OFFICE
Student will NOT be cleared to participate in sports without Health Office clearance.

Student Name________________________________________________Student ID #__________________________Grade level ________

For MKHS Health Office Use Only:
Received completed sports physical form on _________________________________________________
Date/Health Office Stamp/Signature
Student is clear to play sports till ___________________________                                                           updated 3/5/18