ARCHDIOCESE OF MILWAUKEE
Physical Examination Form
***Good for 2 years of competition and must cover the entire duration of
the sport***
***Form will be kept on file and does not need to be completed the 2nd
year***
Student’s Name __________________________________________________________
Gender (M/F) ______________ Grade (as of Fall)
_______________
Date of Examination _______________________
Birth Date _________________
Height
________________ Weight ___________________
The above named student has been examined and there
are no apparent restrictions to participating in interscholastic athletic
activities except as follows: Sports or
school activities in which this student cannot participate are (if none - write
NONE) : ________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
*If approved for only one year of competition, check here. _______
Licensed Physician Signature
_______________________________________________
Physician Name
__________________________________________________________
Physician Address
________________________________________________________
City____________________________________ State
_________ Zip ______________
Phone
( )
_______________________________
ALL BOYS AND
GIRLS PARTICIPATING IN INTERSCHOLASTIC ATHLETICS MUST HAVE THIS FORM ON FILE AT
THEIR SCHOOL/PARISH, PRIOR TO PRACTICE OR PARTICIPATION.
Form 6145(c) Archdiocese of Milwaukee Form revised:
5-6-97 4/1/1989 4/2/1990
2/15/1995 Form 6145.2C