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SPORTS QUALIFYING PHYSICAL EXAMINATION - …

Revised 4/12/17 Page 1 of 4 COPY this Clearance Form for the student to return to the school. KEEP the complete document in the student s medical record. 2017-2018 SPORTS QUALIFYING PHYSICAL EXAMINATION CLEARANCE FORM Minnesota State High School League Student Name: _____ Birth Date: _____ Age: ____ Gender: M / F Address: _____ Home Telephone: _____ - _____ - _____ Mobile Telephone _____ - _____ - _____ School: _____ Grade: ____ SPORTS : _____ I certify that the above student has been medically evaluated and is deemed to be physically fit to: (Check Only One Box) (1) Participate in all school interscholastic activities without restrictions.

Revised 4/12/17 Page 1 of 4 COPY this Clearance Form for the student to return to the school. KEEP the complete document in the student’s medical record. 2017-2018 SPORTS QUALIFYING PHYSICAL EXAMINATION CLEARANCE FORM

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