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HSPD Participant Medical 2013 .pdf

Original filename: HSPD_Participant_Medical_-_2013.pdf
Title: Wednesday, April 22, 2008
Author: pugliesed

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* All Marked Items are required

* Student’s Name: _______________________________________________________________________
Assumption of Risk and Consent for Treatment
I understand that there is an inherent risk of injury with my participation in contact football, and that any such injury
may lead to permanent disability or death. In the event of routine or emergency health examinations diagnostic
procedures, treatment of illness, and/or injuries, I hereby grant permission to the National Football League
Foundation (“Foundation”) and/or its medical staff, physicians associated with other community or Foundation
facilities, as needed, to treat the individual named above.

* Signature of Student: __________________________________________
Signature of Parent: __________________________________________

Date: _____________
Date: _____________

Medical Insurance Information
Indicate the status of your personal health insurance coverage. If covered, the information indicated below must be
provided for all applicable policies.

Choose 1

______ I am not covered by a health/accident insurance policy.
______ I am covered by my own health/accident insurance policy.
______ I am covered by my parent’s health/accident insurance policy.


Health Insurance Company Name & Address: __________________________________________________

* Group #: _______________________________________ *Policy #:___________________________
Physician Consent
Height: ______________

Weight: _________________

Blood Pressure: _____________

Allergies: ______________________________________________________________________________
Medication individual is taking: _________________________________________________________
Previous Medical Conditions: ______________________________________________________________
Previous Orthopedic Conditions: ____________________________________________________________
______ Student cleared for all full contact physical activities (i.e., full contact football)
______ Student restricted from physical activities, reason and/or conditions for clearance (if any)
Conditions for clearance (if any): ___________________________________________________________
Signature of Doctor: ______________________________________________
(Doctor’s stamp of approval also required)

Date: _______________

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