Cheerleading Squad Pre-Participation Health Evaluation
Participant Information
Full Name
Date of Birth
Address
Phone Number
Parent/Guardian Name
Emergency Contact
Medical History
Has the participant ever been diagnosed or treated for any of the following?
Asthma
Diabetes
Seizures
Heart Condition
Concussion
Fractures
Other
If "Other", please specify:
Current Medications (if any):
Allergies (food, medication, etc.):
Past Injuries
Please list any injuries, surgeries, or hospitalizations:
Physician Information
Physician Name
Physician Phone
Consent & Acknowledgments
I authorize emergency medical treatment if necessary.
I acknowledge that participation in cheerleading involves physical activity and risk.
Parent/Guardian Signature
Date