Sample Medical Release Form

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SCEYFL Conference
Southern California East/West– Amateur Athletic Union
Medical Release Form
(PLEASE READ CAREFULLY)
Rev. 04/15
______________________________________________________________________________________________________________________________
SECTION I (Chapter Officials WILL complete SECTION I AFTER candidate has been assigned a specific Team, League and Division)
Beverly Hills
Beverly Hills Youth Football & Cheer
Chapter ________________________________________________
Team City _________________________________________
DIVISION:
ROOKIE
FRESHMEN
SOPHOMORE
JR VARSITY
VARSITY
CHEERLEADING
________________________________________________________________________________________________________________________________
SECTION II
TO BE COMPLETED BY CANDIDATE PLAYER & PARENTS
NO CANDIDATE will be permitted to participate in any activity until SECTIONS 11, III, V and VI of this Contract has been completed in full.
The CANDIDATE PLAYER agrees that he will faithfully abide by the Rules of the SCEYFL Conference to the very best of his ability.
__________________________________________________________
___________________
______________
________________________
Last Name
First
Middle
Birth date
Age as of July 31st
School & grade
__________________________________________________________
______________________________
_________________________________
Address
City
Zip
_____________________________
______________________________
_____________________________
____________________________
Home phone number
Cell number Parent/Guardian
Cell number Parent/Guardian
AAU Membership #:
Name on Policy_____________________________ Primary Medical Insurance Company: _____________________________ Policy #: ________________________
_______________________________________________________________________________________________________________________________________
SECTION III
PARTICIPANT MEDICAL HISTORY
1. Are there any injuries requiring medical attention?
Yes / No
2. Are there any past surgeries or scheduled surgeries?
Yes/ No
3. Is the participant currently under the care of a medical practitioner? Yes/ No
4. Is the participant currently taking any medications?
Yes/ No
5. Does the participant have any allergies (penicillin, bee stings, etc)?
Yes/ No
6. Does the participant have asthma/require the use of an inhaler?
Yes/ No
7. Is the participant diabetic/require medication for diabetes?
Yes/ No
8. Does the participant currently require medication
Yes/ No
9. Does/has the participant have/had seizures?
Yes/ No
10. Does the participant wear glasses or contact lenses?
Yes/ No
11. Does the participant wear a brace or other medical support device? Yes /No
12. Does the participant have physical limitations or medical conditions? Yes/ No
If you answered yes to any of the above questions, please provide the question number and an explanation in the following space:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
I hereby certify that this information is accurate to the best of my knowledge. I understand that this medical authorization may be voided in the
event of injury, illness or accident and my child may not be cleared for participation at such time. Furthermore, I hereby acknowledge that it is
my responsibility to inform my child’s coach or organization official in writing if there is any change in the medical condition of my child. I also
understand that is my responsibility to obtain written permission from my child’s physician on official medical stationary in order to seek
permission for my child to resume participation after any and all such injury, illness or accident.
__________________
PARENT/GUARDIAN: Signature ___________________________________ Print Name ________________________________Date
RELATIONSHIP TO MINOR:
FATHER
MOTHER
LEGAL GUARDIAN
_______________________________________________________________________________________________________________________________________
SECTION IV
MEDICAL EXAMINATION (BY QUALIFIED DOCTOR OF MEDICINE)
COMPLETED ONLY BY A STATE LICENSED MEDICAL PROFESSIONAL
(Doctors stamped required in this section with name of Doctor, address & phone for this portion to be VALID)
Height_______ Weight _______ Blood Pr. _______
Heart
Ears
Nose Teeth
Abdomen
Extremities
Hernia
REMARKS: _________________________________________________________________________________________________
( ) While this examination does not constitute a complete Medical Examination, it does on this date,
RESERVED FOR DOCTORS STAMP
and based upon my observation, meet the requirement for participation in this youth football
program.
( ) Individual examined by me this date is considered not physically qualified to participate in this
youth football program for the following
Reasons: _ _______________________________________________________________
Examining Dr. ______________________________________________
Office Phone __________________________ Date _________________

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