St. Ann's School
217 South Cedar
Independence, MO 64053
252-1024

This form must be completed and returned to the office before your child can participate in St. Ann's Athletic Program. This includes games and practices. Please print out this form, complete it and return it to the school office. Thank you. To return to previous page hit the back button on your browser.


Child's Name________________________________ Sex______ Birthdate_______________________
Address____________________________________________________________________________
Vision: Rt____________ Lt________________ Are glasses required? Yes     No
Hearing: Rt____________ Lt_________________
Heart Condition:____________________________________ Limitations:_________________________
Lungs:___________________________________________ Limitations:_________________________
Temp______ Pulse______ Resp______ BP______ Limitations:________________________________
History:______________________________________________________________________________
Current Medication:__________________________________________________________________________
Allergies:___________________________________________________________________________
Comments:__________________________________________________________________________


I have examined the above named child and verify that the child is in good health and able to participate in St. Ann's Athletic Program.


Physicians's Name:_____________________________________________________________________________
Please Print
Address_____________________________________________________________________________
Street
City
State
 Zip
Phone:___________________________________________ Fax:_______________________________
Physician's Signature:_______________________________________ Date:______________________________