Parental Consent And Release Of Liability Agreement Page 4

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PRE-ACTIVITY CLEARANCE EXAMINATION:
PHYSICIAN AUTHORIZATION
Participant’s Name: ____________________________________________________________________
Camp:Champions Swim and Travel Experience
Current Medications: ___________________________________________________________________
Allergies: ____________________________________________________________________________
I hereby certify that I have examined the above named patient and have found him/her fit to attend and
participate in the camp. I know of no impairments, which would limit his/her participation in all camp
activities except those that I have listed below. I further certify that he/she is free from any and all
contagious diseases.
Restrictions and/or Comments: ___________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Date of Physical Examination (must have been completed December 1, 2015 or after): _______________
Physician's Signature: __________________________________________________________________
Address: _____________________________________________________________________________
Phone: _______________________________________________________________________________

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