*Entire Page Completed By Patient/Parent
I/We hereby give consent for (athlete's name) First Name Last Name __________________________ to represent (name of school) ___________________________ in athletics realizing that such activity involves potential for injury. I/We acknowledge that even with the best coaching, the most advanced equipment, and strict observation of the rules, injuries are still possible. On rare these injuries are severe and result in disability, paralysis, and even death. I/We futher grant permission to the school and TSSAA, its physicians, athletic trainers, and/or EMT to render aid, treatment, medical, or surgical care deemed reasonably necessary to the health and well being of the student athlete named above during or resulting from participation in athletics. By the execution of this consent, the student athlete named above and his/her parent/guardian(s) do hereby consent to screening, examination, and testing of the student athlete during the course of the pre-participation examination by those performing the evaluation, and to the taking of medical history information and the recording of that history and the findings and comments pertaining to the s parent or student athlete on the forms attached hereto by those practitioners performing the examination. As parent or legal Guardian, I/We remain fully responsible for any legal responsibility which may result from any personal actions taken by the above named student athlete.
This form should be placed into the athlete's medical file and should not be shared with schools or sports organizations. The Medical Eligibility Form is the only form that should be submitted to a school or sports organization. Disclaimer: Athletes who have a current Preparticipation Physical Evaluation (per state and local guidance) on file should not need to complete another History Form.
If your athlete has a release or approval to participate from a specialist or other provider, please take a photo or upload the approval documents below.
⚠️ By continuing, you accept that your electronic signature is as valid as a handwritten signature and will be treated as original under applicable law.
© 2019 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment.