Foothill Technology High School Athletic Department Pre-participation Physical Evaluation Clearance Student must return completed form to the Athletics office with the clearance packet.

Name of Athlete: _______________________________________________________ Birthdate: _________________________________________ Grade: _____________ School: Foothill Technology High School



Athlete is cleared without restrictions.



Athlete is cleared with the following restrictions:

______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________



Athlete is not cleared to participate.

Name of Physician: ____________________________ M.D. or O.D. Date: __________ Address: ____________________________________ Phone: ___________________ Signature of Physician: ___________________________________________________

3/1/2014

Preparticipation Physical Evaluation Clearance.pdf

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