Sports and Activities Medical Form

MMA Sports Medical Form

Fill out your medical information carefully
Scholar Name*

First NameLast Name
Grade Level *
Birth Date*

MonthDayYear
Sport Selection

Select the sport your child is interested in.
Type a question*
Parent information

Please include all parent information here:
Parent Name*

First NameLast Name
Phone Number #1*

Area CodePhone Number
Phone Number #2*

Area CodePhone Number
In Case of Emergency
Name*

First NameLast Name
phone*

Area CodePhone Number
Name*

First NameLast Name
phone*

Area CodePhone Number
Name*

First NameLast Name
phone*

Area CodePhone Number
General Medical History
Is the scholar up-to-date all immunizations?*

YesNo
Does your child have a history of heart problems or issues?*

YesNo
Has the scholar had an up to date sports physical?*

YesNoScheduled
Does your child have any food, medication or environmental allergies?*

YesNo
Allergies? Check all that apply*

FoodMedicationEnvironmental
Please list and explain any allergies
Significant Medical History (surgery, injuries, serious illness):
List any Medical Problems (asthma, seizures, headaches):*
Is any medication required?*

YesNo
List any medication taken regularly:*
Please describe
I consent to my scholar participating in tryouts and practices for MMA sports and understand that my child will need an updated physical to participate in full practices. No exceptions. *
Consent for tryouts and practices for MMA Sports
I, First Name* Last Name* understand that participation in tryouts does not mean that my child has made the team and will be subject to a competitive tryout. I, First Name* Last Name* , understand that my child will need to have a sports physical or full physical prior to the first practice for my child to participate in the activity. I, First Name* Last Name* , understand the late pickup from sports practices and events may result in expulsion from the team.
Signature

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MMA Sports Medical Form

Sport Selection

Parent information

In Case of Emergency

General Medical History