8th Gr. Sports Phys.


LADUE MIDDLE SCHOOL
SPORTS PHYSICAL EXAMINATION RECORD 
(This form is patterned after a form cooperatively prepared by the National Federation of State High School Athletic Associations and the Committee on Medical Aspects of Sports of the AMA. This form must be on file in the Athletic Office before a students is permitted to start practice in any sport.)
Name of Student (Print) ________________________________________________
Age _________ 
Birth Date ___________________________
Grade in Current School Year___________
 ____________
 Height Weight

PHYSICIAN’S CERTIFICATION
I hereby certify that I have on this date examined the above-named student and from the limited examination, I could attest no reason for him/her not to participate in supervised interscholastic athletics.
_______He/She can participate. Restrictions________________________________________________
Date_____________
Signature of Physician_______________________________________
Physician Address__________________________________________
Phone_______________ 
Significant past illness or injury:
Please provide any other significant information, which would help us meet the health needs of your child: 
____________________________________________________________
For the continued safety of your child, please notify the school nurse if any of this information changes.
5/17/05

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