Medical Form - Trans-Valley Youth Football League printable pdf download

Trans-Valley Youth Football League

MEDICAL FORM

Participant Name / Birth date: _______________________________________________________________

Assumption of Risk and Consent for Treatment

I understand that there is an inherent risk of injury with my participation and contact football, and that this injury may lead

to permanent disability or death. In the event of routine of emergency health examinations diagnostic procedures, treatment

Parent

of illness, and/or injuries, permission is herby granted to treat the athlete above by the Trans-Valley Youth Football League

medical staff and or physicians associated with other community facilities as needed.

Name of Parent / Guardian: ___________________________________________

Date:__________________

Signature of Parent / Guardian:________________________________________

Date:__________________

Signature of Student: __________________________________________

Date: _____________

Emergency Contact #:_(_____)_________________________

Medical Insurance Information

Indicate the status of your personal health insurance coverage. If covered, the information indicated below must be

provided for all applicable policies.

______I am not covered by a health/accident insurance policy.

______I am covered by my own health/accident insurance policy.

______ I am covered by my parent’s health/accident insurance policy.

Health Insurance Company Name & Address: ______________________________________________________________

___________________________________________________________________________________________________

Group #: _______________________________________

Policy #: __________________________________

Physician Consent

Height: ______________

Weight: _________________

Blood Pressure: _____________

Allergies: ___________________________________________________________________________________________

Medication student-athlete is taking: ______________________________________________________________________

Doctor

Previous Medical Conditions: ___________________________________________________________________________

___________________________________________________________________________________________________

Previous Orthopedic Conditions: _________________________________________________________________________

_____ Student-athlete cleared for all full contact physical activities (full contact football or cheerleading including stunting)

_____ Student-athlete restricted from physical activities, reason and/or conditions for clearance (if any)

Conditions for clearance (if any): ________________________________________________________________________

___________________________________________________________________________________________________

Signature of Doctor: ______________________________________________

Date: ____________

(Doctor’s stamp of approval also required)

Medical Form - Trans-Valley Youth Football League