Parent/guardian Consent-Medical Release And Release From Liability Agreement Form Page 4

ADVERTISEMENT

Physical Examination Information
Date_______/_______/_______
Name of Participant __________________________________________________ Age__________ Birthdate_______/_______/_______
Each participant must EITHER attach a copy of a physician conducted sports examination applicable to this
current academic year OR have a physician complete and then sign the form below.
Clearance:
(circle one)
A.
Cleared
B.
Cleared after completing evaluation / rehabilitation for:______________________________________________
C.
Not cleared for:
Collision
Contact
Noncontact:
Strenuous
Moderately strenuous
Nonstrenous
Due to:_______________________________________________________________________________________
Recommendation:______________________________________________________________________________________________
______________________________________________________________________________________________________________
Signature of physician_______________________________________________________________ Date_______/_______/_______
Physician Address______________________________________________________________________________________________
Physician Phone________________________________________________________________________________________________
C:\Documents and Settings\robertm\Desktop\Medical Forms Revised 120308.doc

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Release And Waiver Of Liability Agreement Form Release And Waiver Of Liability Agreement Form Legal
Parent/guardian Excusal Of An Individualized Education Program Team Member Form Parent/guardian Excusal Of An Individualized Education Program Team Member Form Legal
Parent /guardian Consent And Emergency Medical Release Form Parent /guardian Consent And Emergency Medical Release Form Legal
Parent/guardian Consent And Player Medical Release Form Parent/guardian Consent And Player Medical Release Form Legal
Parent/guardian Consent & Release Of Liability Form For Youth Volunteers Parent/guardian Consent & Release Of Liability Form For Youth Volunteers Legal
Medical Release Form For Minors Parent Guardian Consent Medical Release Form For Minors Parent Guardian Consent Legal
Parental Consent And Release Of Liability Agreement Parental Consent And Release Of Liability Agreement Legal
Parental Authority To Consent To Treatment Of Minor And Release Of Liability Agreement Template Parental Authority To Consent To Treatment Of Minor And Release Of Liability Agreement Template Legal
Form Ch-1 - Parental/guardian Consent Form And Liability Waiver - Diocese Of Birmingham Form Ch-1 - Parental/guardian Consent Form And Liability Waiver - Diocese Of Birmingham Legal
Parent/guardian Consent & Release Form Parent/guardian Consent & Release Form Legal

Related Categories

Parent category: Legal
Download
Go
Page of 4