Required Medical Forms University Of Texas At Austin (Page 4 of 4) in pdf

Required Medical Forms University Of Texas At Austin Page 4

The University of Texas at Austin

Department of Intercollegiate Athletics

REQUIRED MEDICA L FORMS

4 / 4

PRE-ACTIVITY CLEARANCE EXAMINATION: PHYSICAN AUTHORIZATION

You may submit a copy of a completed school physical or a physician’s examination form completed within the last 14

months in lieu of this page.

Participant’s Name

________

Camp (Name / Session / Date)

_______

I hereby certify that I have examined the above named patient and have found him/her fit to attend and

participate in the University Sponsored Summer Sport Camps. 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 within the last 14 months)

☐ Yes ☐ No

Is youth’s immunization record current?

Physician's Signature

_______

Address

_______

City/St./Zip

_______

Phone

_______

Required Medical Forms University Of Texas At Austin Page 4