Sports Physical Clearance

PLAYER’S NAME __________________________________________ PHONE __________________

PARENT/GUARDIAN’S NAME _____________________________________ PHONE ____________

DATE____/____/______ HERNIA_______ HEIGHT_________ HEART_________WEIGHT______

LUNGS__________ BLOOD PRESSURE___________ PASSED_________ FAILED_________

RESTRICTIONS_______________________________________________________________________

REASON FAILED_____________________________________________________________________

PHYSICIAN’S NAME & ADDRESS_______________________________________________________

PHYSICIAN’S SIGNATURE ____________________________________________________________

 

"WARNING"

Participation in competitive athletics may result in severe injury, to include paralysis or death. Changes in rules, improved conditioning, better medical coverage and improvements in equipment have reduced these risks but are impossible to totally eliminate such occurrences from athletics. Players can reduce the chance of injury by obeying all safety rules in their sport, reporting all physical problems, following a proper conditioning program and inspecting their equipment daily. Damaged equipment must be replaced immediately. Even if these requirements are met, and even if the athlete is using protective equipment, a serious accident may still occur.

 

PARENTAL CONSENT, CODE OF CONDUCT & MEDICAL TREATMENT CONSENT

I/We the undersigned, as parents and/or guardians do hereby agree to abide by all Rules & Regulations of the Delta Youth Football League. I/We will adhere to any/all penalties imposed by the League for violations of said League Rules/By-laws. I do give my consent for my child/ward to participate in the Delta Youth Program and do give my/our consent for all medical care prescribed by a duly licensed Doctor of Medicine for my child/ward as his/her parent or legal guardian. This care may be given under whatever conditions are necessary to preserve the life, limb, or well being of my child pursuant to provision 25.8 Civil Code of California.

Is your child currently taking any medication? Yes ______ No _______

If Yes, What? _________________________________________________________________________________

Does your child have any known allergies? Yes ______ No _______

If Yes, What? _________________________________________________________________________________

Does your child have any type of pre-existing heart or other medical condition? Yes _____ No ____

If Yes, What Type? _____________________________________________________________

In Case of an Emergency, Who Do We Notify? ______________________________________________________

AT HOME: _________________________________ AT WORK: ________________________________

DOCTOR TO NOTIFY IN AN EMERGENCY ________________________________________________

PARENT/GUARDIAN SIGNATURE ______________________________ WITNESS ___________________________ DATE ____________