Health History Questionnaire
To participate on a school-sponsored interscholastic or intramural athletic team or squad, each student whose physical examination was completed more than 90 days prior to the first day of official practice shall provide a health history update questionnaire completed and signed by the student’s parent or guardian as mandated by the New Jersey Department of Education.
Email address *
Which School to you attend? *
Parent / Guardian Name *
Your answer
Parent / Guardian Phone # *
Your answer
Parent / Guardian Email *
Your answer
Student First Name *
Your answer
Student Last Name *
Your answer
Age *
Grade *
Sport *
Date of Last Physical Examination *
MM
/
DD
/
YYYY
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