SPORTS QUALIFYING PHYSICAL EXAMINATION
[Pages:5]Revised 7/26/2021
Page 1 of 5
COPY Medical Eligibility Form for the student to returnto the school. KEEP the complete document in the student's medical record.
2021-2022 SPORTS QUALIFYING PHYSICAL EXAMINATION MEDICAL ELIGIBILITY FORM Minnesota State High School League
Student Name: ___________________________________ Birth Date: ___________ Address: __________________________________________________________________________________________ Home Telephone: ______ - ______ - ____________ Mobile Telephone _____ - _____ - ____________ School: ________________________________ Grade: _____
I certif y that the above student has been medically evaluated and is d eemed medically eligible to: (Check Only One Box) (1) Participate in all school interscholastic activities without restrictions. (2) Participate in any activity not crossed out below.
Sport Classification Based on Contact
Collision Contact Sports
Limited Contact Sports
Non-contact Sports
Basketball Ch eerl eadi ng
Di v i n g Fo o tbal l Gy mn as tics Ice Hockey
Lac ro s se Alpine Skiing So c c er Wrestling
Baseball Field Events: High Jump Pole Vault Floor Hockey Nordic Skiing
So ftbal l Vo l l ey ball
Bad mi n ton Bo wl i ng
Cross Country Running Dance Team Field Events: Discus Shot Put Golf Swi mmi n g Ten n i s
Track
(3) Requires additional evaluation before a final recommendation can be made. Additional recommendations f or the school or parents: _________________________________________ _________________________________________
(4) Not medically eligible for: All Sports Specific Sports
Specify________________________________________
Sport Classification Based on Intensity & Strenuousness
III. High (>50% MVC)
Increasing Static Component
Field Events:
Discus Shot Put G ymn asti cs*
Alpine Skiing* Wrestling*
II. Moderate (20-50% MVC)
Diving*
Dance Team
Football* Field Events: High Jump Pole Vault* Synchronized Swimming
Track -- Sprints
Basketball* Ice Hockey* Lacrosse*
Nordic Skiing -- Freestyle Track -- Middle Distance
Sw i mmi n g
I. Low ( ................
................
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