Stallion Athletics Pre-Season Athletic Dire (S86) 698-4622 jkluzak@wcskids.net Twitter: @SHHS_BlacknGold To participate in athletics at Sterling Heights High School the information and check list provided below must be completed and verified by Mr. Kluzak before the first practice. Your stamped Medical Cards will serve as your permission slip to participate for your coach. Name: Grade: Sport: D.O.B.: Check List: Completed Physical After April 15, 2016 (No Blank Areas) Two Completed WCS Medicals Treatment Cards___ Completed WCS Contract or on File____ Passing 4 out 6 Classes from Past Semester___ Athletes Signature Date: Mr. Kluzak’s Signature:. Date:MICHIGAN HIGH SCHOOL ATHLETIC ASSOCIATION, INC. MEDICAL HISTORY = * To be completed by parent or guardian or 18-year-old. + Must be signed below by parent or guardian or 18-year-old, A CURRENT-YEAR PHYSICAL IS ONE GIVEN ON OR AFTER APRIL 15 OF THE PREVIOUS SCHOOL YEAR STUDENT'S NAME: _ = : STUDENT'S ADDRESS: [Saba OF ATER GoaRTAN = FTE TE TAT TORTIE Te NO SOC See eee SE mene Ties Do Bee oc Treanor may i Dery ror eet irayme rreakrentbapyty, iT pe pon you have any ongoing mea eedtions? IF so, please SS ernie ‘Were you en without cae ou mising anceps? aa aes ee eee 3st own megane ae lag eta Yom — ‘Greco at dot yon sot aaa Tecan ein ca Toe aa ag tence bien trim waar iayth fat Tne? Desay aT TERRY HPAL QUESTIONS ABOEEAOE VET WO DONT ACESTINS wero ieee al Tine yor or Ea TN Tere eieaen este ee ae ane else coer | carey ‘cho cued ye spare” taaaoa pope bale aay pa? oc TL ATT Soe ay inka na Tajeae lain nag al npr ertgecrer Sironapan jerome lana bad bg a ph Tne ee SR ERT TAL Saas ai eee | tga tate at (CT gate ong stereos ett sau ge a aa REET Tepe tas ape or Se ae TTT jou naar aeeg oe ‘satel iy en patente howe Hise aera Teja aay Bea my ee REE Feeuene UE enetogan ‘mca ony avn a ca peta es etmeeyeme ene pene orb Sn SLES TT Aastra i aT 2 Ra AL RS TS a rec BRE Stor Tae aT TART Seine aR [a RST TITS a a aT Sato le Fam Teens ooo FETS ae go a aT ae ae oa a ET aja be ET py IMMUNIZATION HISTORY Pe aie ee Nove Hv. Yuta NOD reste = a aT See GOTO TE hne] Srv aa TOUR FAMILY'S SAY HEALN QUESTIONS [WHS ['N||Tinwsoorarbesee skiers cba ToT ome aes Dra Mae ow a Saeed Fcaiawaplon ie igairansnt = re Tape ere Tee aa STAT TTT Copy joes glee? ennaoed? é faa ya dee See i ETT TTT ieee eae eater Taso eee eae owas ees eal i ena iS ae oe ET BUT eee wel el ATION Our Son/Daughter will eomply withthe specie insurance regulations ofthe school district andthe Medial Hisory questions ae as complete and correct 2s possible. Family Insurance Co: Comacti gee WD Signsusesotswien 4 PareniGuardin or 18 Year Olt ‘< DETACH HERE IF NEEDED TO ACCOMPANY STUDENT ATHLETE > —~ Mal NN fel Tie euch ae een eo Student's Name: Grade: “IN EMERGENCY 1) Phone #: Cell CONTACT or 2) Phone #: Cell Family Doctor: Phone: Allergies: Drug Reactions: Current Medications:MICHIGAN HIGH SCHOOL ATHLETIC ASSOCIATION, INC. PHYSICAL EXAM & CLEARANCE & CONSENT FORMS + To be completed by parent or guardian or 18-year-old. + Must be signed in two places on this page by parent or guardian or 18-year-old, ‘A CURRENT-YEAR PHYSICAL IS ONE GIVEN ON OR AFTER APRIL 15 OF THE PREVIOUS SCHOOL YEAR eas STUDENTS COMPLETE LEGAL NAME: STUDENTS onthe DATE OF BIRTH: GRCIEGRADE: 783 PHYSICAL EXAMINATION & MEDICAL CLEARANCE “To be complsted by the examining ID, DO, PA or NP & Returned Diecly te the patent, Categories may beaded or deleted Check Appropriate Column EXAMINATION: (Cine Cet Repco AN) Height Welsh MieFenale BP (Pa: Vins RIN L201 Come: Yes No EDC TGR] TROL FRING —[ ARGENT ARORNTAE FRENS ap rin GSSSTO Ra iy pe aT Ta "spr eg penny mpi NP ey) ar Lye Ne Thea ea SSS ap TER) aT] Tanta aa Rs Sane Sol aa Tania ‘an a CEO Toro ae cs? Ea SS aT Soo {Lcertfy that Ihave examined the above student and recommend him/her as being able to compete in supervised athletic activities NOT crossed out below [BASEBALL - BASKETBALL - BOWLING - COMPETITIVE CHEER - CROSS COUNTRY - FOOTRALL GOLF ~ GYMNASTICS ICE HOCKEY ~ LACROSSE » SKIING - SOCCER - SOFTBALL - SWIMMING - TENNIS - TRACK © FELD ~ VOLLEYBALL - WRESTLING A CURRENT-YEAR PHYSICAL IS ONE GIVEN ON OR AFTER APRIL 15 OF THE PREVIOUS SCHOOL YEAR SIGNATURE OF ERCLE ONE EXAMINER: __ MD DO PA PRINTED NAME (OF EXAMINER: bate STUDENT PARTICIPATION & PARENT OR GUARDIAN OR 18 YEAR OLD CONSENT This pplication to partisiate ia shletiss voluntary on may part an the information submited is tah othe best of my Knowledge. Thave never received money or nogotisble certificate fr merchandise in any amount, nor any emblematic award or merchandise worth mare than tweny-Fve dollars ($25.0) Tor participating in ahetic ‘vents, nor have Tver competed under an assumed name. Ace Thave represeated my’ school n acy spr, I wl not compet in any aside aeletic const inthis spor unt afer my schoo season hasbeen completed. [understand that lam expected to adhere fnly tal established athlete policies of my school dsc nd the Michigan High School Athlete Association, suchas those previously mentioned above as examples but which donot preset all the policies o which Tam subject. Uibreby give my consent forthe above Stale to eng in inescholastc athletics and fr the disclosure tothe MHISAA af informatien otherwise protected by FERPA end BIPAA forthe purpose of determining eligibility for interschoestic athletics; and [undersea the possiblity’ that serious injury may eel from ptcpaing in tlic setivitiss, He'She has my permission to accompany the team as rpember on its ou-ofown tps “fuctiee understand that my son or daughter wll be expected to adhere firmly tal established aha policies ofthe sohool district and the Michigan High School Athlete sociation => Signature of STUDENT: Signature of PARENT: ‘or GUARDIAN or 18 YEAR-OLD =< DETACH HERE IF NEEDED TO ACCOMPANY STUDENT ATHLETE > Vie eh ape oe PE eee) 1 ___, an 18 year-old, or the parent or guardian of __recognize that as a result of athletic participation, medical treatment on an emergency basis may be necessary, and further recognize that school perseanel ‘may be unable to contact me for my consent for emergency medical care. I do hereby conseat in advance to such emengeney care, including hhospital care, as may be deemed necessary under the then-existing circumstances and to assume the expenses of such care. > SIGNATURE OF PARENT OR GUARDIAN OR 18 YEAR-OLDWarren Consolidated Medical Treatment Authorization sai aa Schools Name Birthdate: Home Telephone: Parent (Guardian): ‘Address: Father's Phone (Work): Mother's Phone (Work): Person to Notify if Parent Cannot Be Reached - Nam Address: Phone: Relatio PURPOSE OF THIS CARD: To enable parents or guardians to authorize the provision of emergency treatment for minors who become ill or injured while under school authority when parents or guardians cannot be reached. In the event of an emergency requiring medical attention, I hereby grant my permission to the team physician, trainer or coach to administer first aid to my son/daughter Yes: No: In the event of an emergency requiring further medical attention, I hereby grant my permission to (family doctor) at (preferred hospital) or (if not, possible) to attending physician at the hospital designated by the school staff to attend to my son/daughter. » Tex No:. I expect every effort will be made to contact me in order to receive my specific authorization before any major medical treatment or hospitalization is undertaken. Date:_ Signature:_ HEALTHHISTORY Family Doctor:_” Phone: Hospital: Insurance Company: Insurance Contract Number: Date of Last Physical: Date of Last Tetanus Shot: _ Metical History: YES NO Heart Condition: and pai If So Explain: Epilepsy: ate et Diabetes: aa ae IfSo Please State: Asthma: en aoe IfSo Please State: Other Condition: it pce IfSo Please State: Wear Contacts orGlasses: ae IfSo Please Indicate Which: AllergicToAnyMedication: eae IfSo Please List: PLEASE FILL CARD OUT COMPLETE AND SIGN IT. PLEASE NOTIFY THE SCHOOL IF ANY OF THE INFORMATION (Above or on the other side) CHANGES DURING THE SCHOOL YEAR.