Sports Participation Health Screening
Full Name
Date of Birth
Age
Gender
Male
Female
Other
Contact Email
Sport(s) to Participate
Medical History (check all that apply):
Asthma
Diabetes
Allergies
Epilepsy
None
Other
Are you currently taking any medication?
Yes
No
If yes, please specify:
Do you have any current injuries or conditions affecting participation?
Yes
No
If yes, please provide details:
Emergency Contact Name
Emergency Contact Phone
Relationship
Additional Notes / Concerns