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Sports Physical Basic Information
Student’s Name: _______________________________________________________
Date of Birth: ___________________________________________________________
Gender: ( ) Male ( ) Female ( ) _____________________________________
Race: ________________________________________________________________
Mailing Address: ________________________________________________________
City: __________________________________ State: ________ Zip: ______________
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|I hereby authorize Community Health Care Systems, Inc., to perform a sports physical on this student. |
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|Parent or Legal Guardian’s Name: ____________________________________ |
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|Signature of Parent or Legal Guardian: _______________________________ Date: ____________ |
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|Relationship if other than Parent: _____________________________________ |
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|Parent or Legal Guardian’s Phone Number: _____________________________ |
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***Fill out entire form***
Make sure the parent and student sign and date.
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