Ymca Medical Clearance Form printable pdf download

MEDICAL CLEARANCE FORM

Doctor

Location

_________________________________________________________________________________________________________________________________________

Name of Physician

Physician’s Office

DOB

_________________________________________________________________________________________________________________________________________

Name of Applicant

Phone of Applicant

The above applicant has applied for enrollment in the exercise programs at the YMCA. The exercise programs are designed to start

easy and become progressively more difficult over a period of time. Qualified personnel trained in conducting exercise tests and exercise

programs will administer the exercise programs.

By completing the form below, however, you are not assuming any responsibility for our administration of the exercise programs. If you

know any medical or other reason why the applicants in the exercise program would be unwise, please indicate so on this form.

If you have any questions about the YMCA exercise programs, please call the branch and ask to speak with the Fitness Director.

TO BE COMPLETED BY THE PHYSICIAN

(Report of Physician)

PLEASE WRITE LEGIBLY.

I know of no reason why the applicant may not participate.

I believe the applicant can participate, but I urge caution because:

___________________________________________________________________________________________________________

I recommend that the applicant NOT participate.

I recommend the applicant participate in the following exercise programs:

Water Exercise

Arthritis Exercise

Land Exercise

Strength Training

Mind/Body Exercise

Physician’s Name

__________________________________________________________________________

(please print)

Physician’s Signature _________________________________________________________Date __________________

Address ___________________________________________________________Telephone _________________________

City & State_____________________________________________________________________Zip ____________________

RETURN COMPLETED FORM TO:

Mission Valley YMCA

Toby Wells YMCA

Hazard Center YMCA

(No Pool)

5505 Friars Road

5105 Overland Avenue

7610 Hazard Center Drive #101

619-298-3576

858-496-9622

619-295-1361

FAX: 619-2980-9262

FAX: 858-496-8950

FAX: 619-295-1275

ATTENTION STAFF _______________________________________________PROGRAM NAME__________________

REV 01-01-12JM

Ymca Medical Clearance Form

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