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HISTORY FORM ae tri rene rt Seung te ys Tepystlan ok keep hs fami fe chart) se oe Grave stat Davart Sports | Mosiscas and Wari: Pansat presi ord waco medees and sunlenars herbal and naoal Raya we wore aire re onus a Ss a ‘oh se ns eles da ie ([penienan questions: ‘Yes | to | [ MEDIORL QUESTIONS te | aaa om SaR OTR Pa eae aa En 7 ea eceiiaern nail TRE [PanGow dm Sime Smee Dee Snes Ser 29, Wore you born witha or are you missing aichey. an ey, a testicle eT fae Costu bee carter per amt eae Tere atta cama ae aT T TL Doyou hve ay ews presi eres ae wnorene? | 1 | ooo eee | Eee aa aaron aT TT Srmnenatran a So eeee oo a | SR a tiwine a 4 ae Re ioe ge Sai “was a doctor ens orserad 3 est fr your heart? (or example. ECE, [33, Have you evr bow unctle to mava your arms or waar beng hit | eS SOT eas aa] aaa aS a aT ap eee |= Te eee pei 46 Dayo we pute eae, Sh as Goa a= SNE? | |__trowning, unsepiinad car scant, oF siden intayt deste syncromal? 47 Dayo warty ut your waGh [ aerate cere n eee amt eae han? Fae yu aed w nto sc? ae 7 ee eee 2 te os arin et ps bh you lay Trvech | aad "2, Oo wou have abbone, mode. fant nbey thal oars va? emeeanem ta emir ote by sata that haba of my hrawedge my ansers tthe above questions are sample and earac, tant in dt yo Anan Clagett ia Sa te Wai, an PREPARTICIPATION PHYSICAL EVALUATION THE ATHLETE WITH SPECIAL NEEDS: SUPPLEMENTAL HISTORY FORM Datei Se sexe Orde Schl Sout) Tian 1. Cesena Co yi aeRO mh 3. Ls yu Naso | Hib esrenisi abnor wae dri area 1 yo tes, sre er ory or in pO (2 tos a emg a Do yu we aroun? [atoms veut pacer 7 Dojo ony ail ver ern ot ator Tneton "2 DojosYae ay fue wan eg 15 Hay avon et? ra yur te erred wi a ak ad Ippo cuca Psa Ta 15: youve ad oy? [15 eyes fe ses ca Ee by WoT ans" owes ee Pease iit foun er aay teen EE 1 i a {a paar ara ye [Ease Cay eran 1 ay ott a sei) [ures orien mera [mots rain leg oe [Henasnansone [sie nemo aby ak sy a tot bes fay anu serene ove ates obese. an ao ai Pr Anoiar eyo Pais Ian eos oars Nadie Asean ee Sit Sr oe Anan Oa "Spree, ie ea cena Ses asc Passos ye een see pus man 7 LOIRATION Furs € a PHYSICAL EXAMINATION FORM vine ateofbity ote aout senna, sn 0 “ise ye 9 : 20am au ay aes he ya games weg are or er [oar oy aie Game i ie 7 ey won a a Grand OY 0 aL aaa A EIS | Phan nat synees, gy aca ae acs xan ane, mg ne ot EB BT WE PM aetna ig oa 1 etter aaa pe eee ir SoA Toe a. (eer a (Le hechak se at 1 Fray ant 1 Fercetirsos osm — - = — eee garzjaatonpysialertaon The ae nes ot pram para iil conics ‘1a 3 sti ay ole 948 male iat ae set ene ls ar. ans sae enanenu araie reed 9 sata eeu 3 aga aati to. sara ha ays uf pga, EPARTICIPATION PHYSICAL EVALUATION CLEARANCE FORM WISCONSIN INTERSCHOLASTIC ATHLETIC ASSOCIATION — ATHLETIC PERMIT CARD (erator Tye) ALL STUDEITS PATIPATING W BITERSCHOLAST ATHLETICS MUST KAVE TMS CARD OW FLEAT THER SCHOOL PRIDE TO PRACICE OR PATNEATIN ysis oramietion tke Apt and treats ta aiowing ta soa yar; physical examination tke fre Aol svat al er ha ranlaer ofthat scl ae a eatin Soo yar, ante (as et ee) (Mitts) at aren gt. See___vase_ se ow Prost aes _ Telpone ig (Ociered wtotrritn ‘bla it owog gotten: anacieed —arendngiuseeauaton —Foraltipons Faerie pu: osonmenates: : z e ‘nae amine ie nove ames inthe spon) azote toe. Ase has tan eared ar partltion» phyian may resend ba Feeeagareny 2 copa the pepiyatn pyl lation. Te ate dns ot roseal apparel ea cael nrs ta prs a-ha psi na ison recast ean eae arate eho te reqs ee ares, Neon sear te ee fo nl poo is satan ib otal eonaqunees ar ompisy ela oe white ond a at ys Pay. SIQUATURE OF Liceen Physi (ME OR DO}APHR bin ane sagem ste Bp cate + Pyscins may ators Nase Prettone or Physic Astaro sta hs carte physica agra othe mana ath ne wth hich ie py sean is aa, Patents Pave ol Empoymont Fart Dent rity Pryscan Subscriver Member Name (Prey luted) — Emergency Information ergioe ‘omer lntormatan mediation, ae) linmuuieatons O.Uptad 9 otarusetreria: meses, mumps, bala: hapa (s02 ached documentation) Not upto date -specty. 6 nuerza polars: sreurecocsal meinaacoecal vera | eraby glue my permission for ina above named stuset fe pracca and compet and represen ths sohoa in WIAA approves mteecholase spots ‘xooot nose reseed on mis ard 2, Pursuant otha requitrone of the Hath Inusnee Posty and Ascoutaity Aet of 1996 an tho rogstons promulald thseureroalacivny known 5 HIPAA", lauhorze neath cao provdrsol te sider anos dove, neuang smergency medica pa’sonse anders ane peacoat tray 9 mtendeg an trees ayant cr ration. to aesloalaxshan este meal irstion garding ha ny ard men ot stent soon schon dita personel sich s bul ole to: Piacoa, All Direct, Alec Trainer, Tear Physi. Tear Gatch Adinirain Asstt tee tite Bestar ser otar profesional natn care provides, or pupces ol oar, emerjney ara and ini 2231-920", |ATURE OF PAHENTIGUARDIAN bare

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