Medical Release Form
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1MEDICAL RELEASE FORM
The following is to be filled out by the parent or guardian of the participant.
Is the participant under a doctor’s care? If so, explain.
1.
2.
Allergy to any medication?
Yes
No
If yes, explain.
3.
Chronic medical conditions (i.e. diabetes, asthma, murmur etc..).
4.
Should the participant limit their physical participation during athletic activities?
Yes
No
If yes, explain.
5.
Is the participant taking any medications?
Yes
No
If yes, explain.
6.
In the last year has the participant:
Explain.
Had a major illness
Yes
No
Been hospitalized
Yes
No
Had surgery
Yes
No
Been unconscious
Yes
No
Broken Bones
Yes
No
Back Injury
Yes
No
Knee or ankle injury
Yes
No
IT IS THE SUGGESTION OF ROSWELL CHEERLEADING CENTER, INC THAT EACH
PARTICIPANT HAVE A MEDICAL EXAMINATION PRIOR TO PARTICIPATING IN THIS
ATHLETIC ACTIVITY.
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