UUFL

                                        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

E-Mail

Twitter

               Contact Us  By E-mail 

         Social Media  COMING SOON

  • UUFLathletes@gmail.com
  • @TheUUFL
  • Grey Facebook Icon
  • Grey YouTube Icon

© 2019 by The Universal Ultimate Football League