Physical Exam Clearance Form printable pdf download

PHYSICAL EXAMINATION

CLEARANCE FORM

This form must be on file in the school athletic office (see address below) before practicing with

any athletic team.

Student Name: _________________________________ Birth Date: __________ Age: ___ Gender: M / F

Address:

__________________________________________________________________________________

Home Telephone: _____ - _____ - ________

Grade: ____

I certify that the above student has been medically evaluated and is deemed to be physically fit to: (Check One

Box) Parent or Guardian Signature:_________________________________

Date:__________

(1) Participate in all school interscholastic activities without restrictions.

(2) Not cleared for:

All Sports

Specific Sports

I have examined the above named student and found that the athlete does not present

apparent clinical contraindications to practice and participate in the sport(s) as out-

lined above.

A copy of the physical exam is on record in my office and can be made available to the

school at the request of the parents. If conditions arise after the athlete has been

cleared for participation, the provider may rescind the clearance until the problem is

resolved and the potential consequences are completely explained to the athlete (and

parents/guardians).

Examiner Signature:

Date of Exam: ______________

Print Examiner Name:

Address:

Office Telephone: _____ - _____ - ________

EMERGENCY INFORMATION FOR: ______________________ Grade: ____

STUDENT ATHLETE

Allergies – Drug Reactions – Current Medications:

Other Special Medical Information:

_____________________________________________________________________

Emergency Contact: ______________________________ Relationship:

Telephone:

(H) _____ - _____ - ________ (W) _____ - _____ - ________ (C) _____ - _____ - ______

Personal Physician ___________________________ Office Telephone _____ - _____ - ______

For questions concerning this document please contact :

Tom Parlanti

Athletic Director

The Lexington School

1050 Lane Allen Road

Lexington, KY 40504

859-278-0501 ext. 1262

Physical Exam Clearance Form

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