Update annually for all participants. Activity: Competitive Shooting Sports activities or programs with moderate level of
activity similar to that of home or school. Medical care is readily available. Current personal health and medical summary
(history) is attested by parents to be accurate. This form is filled out by all participants and is on file for easy reference.
A medical evaluation (physical examination) also is required if Athlete is currently under medical care, or has had an injury or
illness during the past 6 months that limited activity for a week or more, has ever lost consciousness during physical activity,
or has suffered a concussion from a head injury.
PERSONAL HEALTH AND MEDICAL HISTORY
To be filled out by Athlete, Parent or Legal Guardian, or adult participant. Please print in ink.
IDENTIFICATION
Name____________________________________________________ Date of birth_______________ Age_______
Sex_______ Name of parent or guardian _____________________________________________________
Telephone__________________ Home address __________________________________ City_______________________
State__________ Zip_____________ Business address ______________________________
City_______________________ State__________ Zip_____________
If person named above is not available in the event of an emergency, notify:
Name_______________________________________ Relationship____________________
Telephone____________________ Name _______________________________________
Relationship____________________ Telephone____________________
Name of personal physician _______________________________________________Telephone________________
Personal health/accident insurance carrier _________________________________Policy No.____________________
I give permission for full participation in Keller High School Clay Target Team programs, subject to limitations noted herein.
Athlete (and Athlete's parent/legal guardian if Athlete is a minor) further agrees to pay any and all medical
costs, expenses and charges to release, waive, discharge and hold harmless Keller High School Clay Target
Team and each of their respective directors, officers, employees, agents or volunteers, from and against any
liability or any claim or demand arising from or connected with such medical care and treatment.
In case of emergency, I understand every effort will be made to contact me (if participant is an adult, my spouse or next of
kin). In the event I cannot be reached, I hereby give my permission to the licensed health-care practitioner selected by the
adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication
for my child (or for me, if Athlete is 18 or over).
Date______________ Signature of Athlete ______________________________________________________________
(If Athlete is a minor under 18)
Date ______________ Signature of parent/guardian or adult __________________________________________
KHSCTT-MEDFORM v1.0
6/18/2021
Page 1 of 2
NAME _______________________________________________ DATE: ____________
PERSONAL HEALTH AND MEDICAL RECORD
ALLERGIES: Food, medicines, insects, plants Yes ■ No ■ Explain:____________________________________________
GENERAL INFORMATION:
ADHD (Attention-Deficit
Hyperactivity Disorder
Asthma
Cancer/leukemia
Yes No
■
■
■
Yes No
Convulsions/seizures
Diabetes
Heart trouble
■
■
■
■
■
■
Hemophilia
High blood pressure
Kidney disease
■
■
■
Yes
No
■
■
■
■
■
■
Explain:______________________________________________________________________________________________
Please list ALL medications taken in the 30 days prior to participating in the Competitive Shooting Sports activity for which this
form is to be used ______________________________________________________________________________________
List any medications to be taken during the sports activity _______________________________________________________
List any physical or behavioral conditions that may affect or limit full participation in physical sports competition:
________________________________________________________________________
List equipment needed such as wheelchair, braces, glasses, contact lenses, etc.: _______________________
Tetanus toxoid ____________________
Diphtheria
____________________
Pertussis
____________________
KHSCTT-MEDFORM v1.0
6/18/2021
Measles ____________________
Mumps ____________________
Rubella ____________________
Polio _____________________
COVID-19_________________
__________________________
PHOTOCOPYING THIS FORM IS PERMITTED.
Page 2 of 2
DATE: _______________
Immunizations: (Give date of last inoculation.)
NAME ____________________________________________
Check all items that apply, past or present, to your health history. Explain any “Yes” answers.