Return to Activity Clearance Form
Complete this form to request clearance for resuming physical or athletic activities after an absence.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
What type of activity are you returning to?
*
Please Select
Sports Team
Physical Education Class
Recreational Activity
Other
Reason for Absence
*
Illness
Injury
Other (please specify)
Date of Last Participation in Activity
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please describe the illness, injury, or reason for absence.
*
Are you currently experiencing any of the following symptoms? (Check all that apply)
*
Fever
Cough
Shortness of breath
Fatigue
Muscle aches
None of the above
Other
Have you received medical clearance to return to activity?
*
Yes, from a healthcare provider
No, but I feel fully recovered
No, still under evaluation
Emergency Contact Name and Phone Number
*
Signature of Participant or Parent/Guardian (if under 18)
*
Submit Clearance Request
Submit Clearance Request
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