Penn Harris Madison Middle School Athletics 2017 - 2018
Athletic Medical Insurance Certification
NAME: _________________________________ at SCHMUCKER
(student) (Name of School)
Birth Date: ___________________________ LAVON DEAN-NULL
(Principal)
Grade in the Fall: (Circle One) 6 7 8 Gender: (Circle One) Male Female
Parents: I hereby give my consent for the aforementioned student to participate in the following interscholastic sport(s) circled below:
Cross Country Football Volleyball Wrestling Cheerleading
Girl's Basketball Boy's Basketball Boy's Track Girl's Track
I will NOT hold school authorities responsible in case of accident or injury as a result of this participation.
He/She: (ONE OF THE ITEMS MUST BE CHECKED)
(1) Has school student accident insurance _______
(2) Has family insurance coverage and declines
student accident insurance offered through
PHM _______
A parent/guardian must purchase the school student athletic insurance when family insurance coverage is no longer available in order for a child to participate in Middle School Athletics.
SIGNED: _________________________________ _________________________________
(Parent/Guardian) (Student)
DATE: _________________________
Physician’s Certificate
PHYSICIAN: I have examined the heart action, blood pressure, lungs, and general physiological condition of aforementioned student and believe him/her to be physically fit to participate in all interscholastic sports except _______________________________ during the present year. I have found him/her to be free from serious heart
and lung disorder.
Date: _____________________________ Physician: ____________________________________________
Previous to a student’s first practice or tryout for any interscholastic athletic contest, he/she shall have on file in the principal’s office for each school year, a Parent & Physician’s Certificate of physical fitness, giving written consent from the father, mother or guardian for such athletic participation. According to the IHSAA, a physical executed on or after May 1st is good for the remainder of the current school year and for the next school year. The physical examination shall be made prior to the student’s first practice or tryout for any interscholastic contest by a physician licensed to practice medicine in Indiana. A student properly certified to participate in interscholastic athletic activities who is absent from school or who is physically unable to practice for five consecutive days due to illness or injury, must present to his principal a statement from a physician licensed to practice in Indiana that he/she is again physically fit to participate in inter-school athletics.
