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School Info
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Faculty
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Parents
Annual Calendar (PDF)
Bell Schedule
Catering/Lunch Orders
Forms & Documents
Payments
Parental Rights Handbook
PTO
Transcript Request
Students
Advising
Announcements
Course Catalog
Dual Enrollment
Parking Permits
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Form – Physical Evaluation – Participation
SocialTech
2017-02-16T23:29:23-07:00
Physical Evaluation
Please fill out the form below.
This MEDICAL HISTORY FORM must be completed annually by parent (or guardian) and student in order for the student to participate in athletic activities. These questions are designed to determine if the student has developed any condition which would make it hazardous to participate in an athletic event.
Student's Name
*
First
Last
Sex
*
Age
*
Date of Birth
*
MM slash DD slash YYYY
Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
*
Grade
*
School
*
Personal Physician
*
Personal Physician Phone
*
In case of emergency, contact:
Name
*
First
Last
Relationship
*
Phone
*
Type of Phone
*
Select One...
Home
Cell
Work
Explain "Yes" answers in the box below**. Circle questions you don't know the answers to. Any Yes answer to questions 1, 2, 3, 4, 5, or 6 requires further medical evaluation which may include a physical examination. Written clearance from a physician, physician assistant, chiropractor, or nurse practitioner is required before any participation in UIL practices, games or matches.
Name
This field is for validation purposes and should be left unchanged.
Δ
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Heritage Academy Mesa: 32 S. Center, Mesa, AZ 85210
Phone: (480) 969-5641
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