Athlete Medical Physical Clearance Form

               2019 SEASON  (one application per Athlete) (PRINT APPLICATION)

Important: This application along with the Birth Certificate of athlete & Athlete Application Form, receipt of payment all must be complete and brought to Registration Day / Aka Chaos Day to complete the process and the athlete to be approved to participate in the season



Athlete’s Name_________________________________________________________




 Address, Phone Number








Age____________________                       Date Of Birth________________________



Medical Center Name & Address 








Medical Center / Hospital ID number (CCN / NPI)__________________________________________________________


Physician’s  Name (Print)________________________________________________________________________



1.   Have you given the athlete a physical ?


                 NO                         YES  





3.  Does this athlete have any health problems such as hart, lungs , breathing etc that will be harmful to the athlete if they participated in this spot ?       (Circle One)


                  NO                         YES ( if yes please explain ) 







3.  Do you as a physician think that the athlete is physical able to run, jump, fall, etc out doors playing youth sports for a team 3 hours a week for 4-8weeks      (Circle One)


                  NO  (if no please explain)                          YES   














Physician’s Signature______________________________________________                        Date________________________________________

Print and complete with your Doctor then push next



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