This report should be completed by the physician and returned to:

Student's Legal Name GradeSchool
Address
Date of BirthSexPhone Number
Parent or Legal Guardian

History of recent serious illness/injury/surgery __________________________________________ __________________________________________ __________________________________________	= Normal. Describe impairment:
Allergies/Asthma/Hay Fever___________________ ________________________________________	Skin_______________________________________
Current Medication___________________________ __________________________________________	EENT:_____________________________________
Height____________Weight__________________	Lymph Glands_______________________________
Blood Pressure____________Pulse______________	Heart______________________________________
Hemoglobin/Hct_____________________________	Lungs_____________________________________
Urinalysis: Sp. Gr.____________Sugar__________	Abdomen__________________________________
Albumin________________Micro_______________	Orthopedic_________________________________
Visual Acuity: Rt._______Lt._______Both_________	Scoliosis: Yes_______No______X-rays__________
Hearing Acuity: Rt.______Lt._______Both_________	Treatment_________________________________
Recent Immunization Boosters	Neurological findings_________________________ _________________________________________
DPT___________Dt___________Td_____________ Measles____________________________________	Did you recommend a referral?__________________ _________________________________________
Polio______________________________________ Mumps________________________________	Full Activity________________________________
Rubella____________________________________ TB Test______________________________	List restricted Activities_______________________ _________________________________________ _________________________________________
Other______________________________________ Other_________________________________

Date of ExaminationSignatureM.D.

Parent Permission For Interscholastic Athletics
__________________________is given my permission to participate in interscholastic athletics. I have read this form and agree that my son/daughter will abide by the training rules. This form must be signed and returned to the office before a student will be permitted to practice.

Athlete's SignatureParent's Signature

Student Name

It is recognized that participation in sports activities may lead to injury. In recognition of this, the undersigned hereby waive any and all claims which may arise out of the named student's participation in Holy Family School System activities. The undersigned release Holy Family School System, it's members, coaches and all persons associated with said school system from any and all claims.

Furthermore, the undersigned recognizes that it is our responsibility to obtain insurance coverage for the named student in event of injury. Regardless of whether or not my individual school offers a separate school and sports insurance policy, it is our responsibility to see that our child is covered either by our own health insurance or by a separate policy.

Parents/GuardiansDate

Parents/GuardiansDate

**Please print these forms and use for your doctor visit and insurance waiver. Be sure all signatures and information is complete and turned in to the office before athletic activity begins.

Student's Name (Last, First, MI)
Age GradeDate of BirthToday's Date
Student ID#
Parent/Guardian Name(s)
Student Address
Parent/Guardian Home Phone Number(s)
Parent/Guardian Place(s) of Work
Parent/Guardian Work Phone Number(s)
In an emergency, when parent/guardian cannot be notified, please contact:
RelationshipPhone
RelationshipPhone
Family PhysicianPhone
Preferred HospitalPhone
Family DentistPhone
Date of last tetnus booster:(month/year)
Do you wear: Glassesyes no / Contactsyes no / Denturesyes no
List any know allegeries, drug reactions, or other pertinent medical information. (Diabetes, seizures, history of
head injury with unconsciousness or confusion, medications, etc.)


Please note and date any new injury information here:

Iowa law requirees a parent's, or legal guardian's, consent before their son or daughter can receive emergency treatment, unless, in the opionion of a physician, the treatment is necessary to prevent death or serious injury.
As the parent(s), or legan guardian(s), of the child named on the front of this card, I (we) authorize emergency medical treatment or hospitalization that is necessary in the event of an accident or illness of my (our) child. I (we) understand that this written consent is given in advance of any specific diagnosis or hospital care. This written authorization is granted only after reasonable effort has been made to contact me (us).

Parent's/Guardian's signature
Date
Consent for Treatment endorsed by the Iowa Chapter of the American Academy of Energency Physicians