St. Clement Sports Participation Health History  

All applications should be mailed to:
St. Clement Church
172 Freneau Avenue
Matawan, N.J. 07747-3400
c/o Athletic Department (SCAC)
 

Name ____________________________ Age ______ Grade ______ Date _________

Address ________________________________________________________________

Phone __________________________________________________

Sport ___________________________________________________

Home email address ___________________________________________________

Business email address ___________________________________________________

To be completed by parent and athlete:
 

1. Have you ever been medically advised NOT to play any sport?

Yes    No

2. Do you have any concerns about participating in sports?

Yes    No

3. Have you ever had an illness that:

    a. Required you to stay in the hospital?

Yes    No

    b. Lasted longer than a week?

Yes    No

    c. Caused you to miss 3 days of practice or competition?

Yes    No

    d. Is chronic (e.g., asthma, diabetes, etc.)?

Yes    No

4. Have you ever had an injury that:

    a. Required you to go to the emergency room or see a doctor?

Yes    No

    b. Required you to stay in the hospital?

Yes    No

    c. Required x-rays?

Yes    No

    d. Caused you to miss 3 days of practice or competition?

Yes    No

5. Are you allergic to anything?

Yes    No

6. Do you have a bleeding disorder?

Yes    No

7. Are you under a doctor's care?

Yes    No

8. Do you take daily or regular medications?

Yes    No

9. Have any members of you family under age 50 had a heart attack, heart problem or died unexpectedly?

Yes    No

10. Have you ever had a seizure, convulsions, been unconscious or suffered memory loss?

Yes    No

11.Do you have a history of heart, blood pressure or chest pain problems?

Yes    No

12. Have you ever experienced heat stroke or fainting after exercise?

Yes    No

13. Do you have any vision impairments or wear glasses/contact lenses?

Yes    No

If you answered Yes to any of the above questions, please explain below:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
____________________________________________________________________________
 

Primary physician:

Name ___________________________________

Address _________________________________

Phone ___________________________________

Medical Insurance Coverage ____________________________

Please list two persons we can contact if we are unable to reach you in the event of an emergency:

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