Sports Physical Clearance Form
Complete this form before athletic participation so a clinician can review health history, perform the physical exam, and determine sports clearance.
Athlete Information
Athlete Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Grade / Team Level
*
Please Select
Pre-K
Kindergarten
Elementary
Middle School
High School
College
Club
Other
Sport(s) Requested
*
Baseball
Basketball
Cheerleading
Football
Soccer
Softball
Swimming
Track & Field
Volleyball
Wrestling
Other
School / Club Name
*
Medical History and Current Health
History of heart condition
*
Yes
No
Medical history affecting sports participation
Asthma
Concussion
Fracture or surgery
Other condition
Current medications
Allergies
Emergency Contact and Clearance
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Clinician Examination Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Clearance Status
*
Cleared
Cleared with Restrictions
Not Cleared
Clinician Notes or Restrictions
Submit
Should be Empty: