Medical Clearance Form The Ymca


Medical Clearance Form
Dear Doctor:
____________________________________________________________ has applied for enrollment in the
YMCA Diabetes Prevention Program. This program involves losing weight through healthy eating and
being more physically active. The exercise programs are designed to start easy and become
progressively more difficult over a period of time. Brisk walking is recommended as the primary
method of increasing physical activity.
By completing the form below, you are not assuming any responsibility for our administration of the
exercise programs. If you know of any medical or other reasons why participation in the YMCA
Diabetes Prevention Program by the applicant would be ill-advised, please indicate so on this form.
If you have any questions about the YMCA Diabetes Prevention Program, please call Cyndi Portteus at
(317) 266-9622.
Report of Physician
I know of no reason why the applicant may not participate.
I believe the applicant can participate, but I urge caution because
The applicant should not engage in the following activities:
I recommend that the applicant NOT participate
Physician signature ____________________________________________ Date ____________
Name (printed) ______________________________________________________________________
Address _________________________________________ Telephone ______________________
City and State __________________________________________ Zip ______________________
Please fax form to:
Diabetes Prevention Program
YMCA of Greater Indianapolis
(317) 266-2845


00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical