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Get MI MHSAA Medical History

YEAR PHYSICAL IS ONE GIVEN ON OR AFTER APRIL 15 OF THE PREVIOUS SCHOOL YEAR LAST FIRST MI SEX STUDENT’S NAME: GRADE DATE OF BIRTH --NUMBER AND STREET AGE --- CITY ZIP STUDENT’S ADDRESS: NAME OF FATHER OR GUARDIAN WORK PHONE NAME OF MOTHER OR GUARDIAN FAMILY DOCTOR OFFICE PHONE WORK PHONE STUDENT’S HOME PHONE MEDICAL HISTORY GENERAL QUESTIONS YES NO Has a Doctor ever denied or restricted your participation in Sports for any reason? YES NO Has a doctor ever told you .

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