Metro Atlanta Youth Football League Physical Evaluation Form
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1METRO ATLANTA YOUTH FOOTBALL LEAGUE PHYSICAL EVALUATION FORM
Full Name
Gender
First
Middle
Last
Birthdate
/
/
Grade
School
Home Address:
Street (do not use P.O. Box)
City
Zip Code
Parent (s) Name
Home Address:
(if Different than Youth)
Street (do not use P.O. Box)
City
Zip Code
Family Physicians Name
Physicians Address:
Street (do not use P.O. Box)
City
Zip Code
YES
NO
PARTICIPANT’S HISTORY
• Has this athlete ever had hospitalization, surgery, injury, or serious or chronic medical illness?
• Is this athlete now under the care of a physician or taking any medication?
• Has any physician ever recommended or do you feel that there should be limits placed on
participation in competitive sports?
• Does this athlete have any known allergies to medications?
IF YES, TO ANY OF THE QUESTIONS PLEASE SPECIFY ON BACK OF FORM.
I certify that the medical history on this form is complete and accurate. I understand that this will serve as the basis for determining that my
child listed above may compete in recreational youth sports. I understand that this evaluation is only to determine fitness for recreational youth
sports and is not to replace of a regular medical examination. In case of an emergency or accident during the recreational activity, I hereby
grant permission to the Association to obtain the services of a physician or to transport said child to the hospital if it is deemed necessary
Parent Signature: _______________________________________________________ Date: ___________________________
HISTORY AND CONSENT MUST BE COMPLETED PRIOR TO THE PHYSICAL EXAMINATION
Height
Weight
Pulse
Vision
Blood Pressure
R20
L20
Normal
Abnormal
Normal
Abnormal
Neck
Heart
Lungs
Hernia
Abdomen
Spine
Joints
SHOULD THERE BE ANY LIMITATIONS PLACED ON ATHLETIC PARTICIPATION?
Cleared to Participate?
___________________
On the basis of the above examination, together with the medical history furnished to me by the child’s parent or guardian, I have found no
indications of physical or medical reasons which would make it inadvisable for the above named child to engage in supervised recreational
athletic activities, except as indicated above.
Physician’s Name, Address and Phone Number (Print and Stamp)
Physician’s Signature _____________________________________________________ Date of Examination ___________________________
This Physical Evaluation Form expires one calendar year from date of examination.
AUTH IN _____
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