ARCHDIOCESE OF SAN ANTONIO
Physician’s and Parent’s Certificate for Athletics
Student’s Name ________________________________________ Date of Birth ___________________
School ________________________________________________
PHYSICIAN’S REPORT
Height ________ Weight ________ Body Type ___________________________________________
Eye ________ Ear ________ Nose ________ Throat ________ Hearing ________
Heart ________ Blood Pressure ________ Lungs ________
Joint Function: Shoulders ________ Elbows ________ Hips ________ Knees ________
Dental (Cavities, Bridges, False Teeth, Retainer, Appliance) (Circle defect)
Other ________________________________________________________________________
Genitourinary _____________________ Hernia ___________________________
Is student taking any medications routinely ? Yes ___ No ___ Explain_________________________
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I hereby certify that on this date I have examined the above named student as indicated by items
checked and recommend him/her as being physically able to participate in all the supervised
activities listed with the EXCEPTION of those circled below:
BASEBALL BASKETBALL CHEERLEADING CROSS COUNTRY FOOTBALL
SOCCER SOFTBALL TENNIS TRACK & FIELD VOLLEYBALL
D
ate ________________ Signature of examining Physician___________________________________
**********DO NOT DETACH *******************DO NOT DETACH *********************
I hereby give permission for the above named student to compete in Archdiocesan approved sports,
and go with the coach or other school representative on any trips. The parent herewith grants
permission for school employees to secure medical services for the above named student if necessary.
The undersigned agrees to be responsible in the safe return of all athletic equipment issued by the
school to the above named student.
Date __________ Signature of Parent or Guardian ________________________________________
Evidence of Student Insurability:
Health Insurance Company: _______________________________________ Policy #: _____________________
Other Insurance Information: ___________________________________________________________________