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HMHP Physicals Info for 2012 2013 by rZnVMoHA

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									                                                    ATTENTION

                          PARENTS OF 7TH THRU 12TH GRADE ATHLETES:
                                       SPORTS PHYSICALS
                        are being given by Competitive Edge Sports Medicine
                   for Niles McKinley & Niles Middle School Student Athletes only!
                                            Monday, May 21, 2012
                                        At: Niles McKinley Gymnasium
                                             From: 4:00 – 6:00 PM
                                 WITH pre-registration athlete forms AND
                               pre-payment of $15.00 check or money order
                                  Cash ONLY accepted day of physicals.
    Please completely fill out ALL forms (front & back) AND the front of your physical form
                          and return it to your school office WITH the
                           $15.00 check or money order made out to
                            HMHP (Humility of Mary Health Partners)
              (Athlete forms & money will not be accepted if not completed)
*If athlete has any known medical condition(s), please see your family physician for physical or
                         have a written clearance from your physician
                         to have physical given by Competitive Edge.
                            Please complete the bottom and return with
               Athlete forms & check or money order by Wednesday, May 16th, 2012

                                                       Thank You!



  ---------------------------------------------------------------------------------------------------------

 Original physical kept for Athletic Dept. and a copy given to parent/guardian day of physical!
  Date__05___/__21__/2012

 Athlete’s Name__________________________________________________
                    First              Middle I.          Last

 Name on Check/MO ______________________________________________

 Check /MO #____________________

                                   CIRCLE 7
 Grade for UPCOMING school year Circle                              8       9      10       11       12


                                    Walk-ins welcomed – Cash accepted!
 Important Reminder
     If you cannot stop in to pick up all the
athlete forms, please print the following and fill
   out before you attend the clinic for sports
                    physicals:
             Emergency Medical Form
              HIPPA/Physcial Forms
Eligibility Form (Needed for 9-12 Grades Only)
                 Insurance Form
                Concussion Form

								
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