Medical Clearance Form printable pdf download

Medical Clearance Form

__________________________________________________

______________

Last Name

First Name

Middle Initial

Date of Birth

Gender: ___

___

Age: ____________

Grade: _________________

Parent’s Name ___________________________________ Phone: _________________

______

Cleared without restriction

______

: ___________

Cleared, with recommendations for further evaluation or treatment for

________________________________________________________________________

I certify that this athlete is medically qualified to participate in football.

I also certify that I am a licensed physician or work directly with a

licensed physician.

Parent’s Signature: __________________________________

Date: ___________

Physician’s Signature: ________________________________

Date: ___________

Physician’s Address: ______________________________________________________

Physician’s Phone #: _________________________________

Medical Clearance Form