ATHLETIC RELEASE FORM    Student Name ________________________________________    

Grade ________ 

 

   Health Insurance Carrier: ______________________________ Policy # __________________________     MEDICAL CLEARANCE:  ​ You must include a doctor's signature and medical office stamp below OR attach an  official physician physical form.​   ​ All physicals must be dated within the past year.      

 

            ​ MEDICAL OFFICE STAMP BELOW 

Physician Name (please print)​  _______________________________________     Physician Signature X​ _________________________________________    Date ______________   

 

 

*This certifies that the above named student is physically able to participate in athletics     

Known Student Health Conditions/Limitations 

____________________________________________________________________________    

____________________________________________________________________________     

Athletic Clearance Form.pdf

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