Page 1 and 2 are REQUIRED to tryout/play a sport annually.

Please make sure that all boxes are completed. Most forgotten boxes are listed below: Please take note

Part 1 Physical

Date of student’s last Diphtheria/Tetanus shot? (month/day/year) (Between the personal information and the questionnaire)

Sports/Activities Trying Out for: (list all sports please) (Top right side)

Signature of Parent and Athlete: (at bottom of page)

Part 2 Physical

Follow up questions and more sensitive information: (completed by doctor) something must confirm this was done.

DOCTOR’S CLEARANCE: This student is medically cleared to participate in sports/activities: YES____NO_____(Doctor checks one) (shaded area at bottom of the page)

Doctors Signature and Date of Physical: (Bottom right of page)