Transcription of PHYSICAL EXAMINATION CLEARANCE FORM
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PHYSICAL EXAMINATION CLEARANCE FORM
This form must be on file in the school before practicing with any athletic team Student Name: _____ Birth Date: _____ Age: ____ Gender: M / F Address: _____ Home Telephone: _____ - _____ - _____ School: _____ Grade: ____ Sports: _____ I certify that the above student has been medically evaluated and is deemed to be physically fit to: (Check One Box) (1) Participate in all school interscholastic activities without restrictions. (2) Not cleared for: All Sports Specific Sports _____ Cross out specific sports below not cleared for participation.
physical examination clearance form • To be completed by parent/guardian or 18 year old or older student -athlete; please take time to complete the form to ensure the good healt h and safety of the student -athlete
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