BELTON TIGER YOUTH FOOTBAL LEAGUE (BTYFL)

2014 PHYSICAL FITNESS & MEDICAL HISTROY FORM

Section II: THIS SECTION IS TO BE COMPLETED ONLY BY A MEDICAL PROFESSIONAL

Name of
Participant__________________________________________________________________________________

(Please check the following if healthy or note otherwise):

Height :

Weight:

Eyes:

Ears:

Mouth:

Nose & Throat:

Respiratory:

Cardiovascular:

Neurological:

Muskoskeletal:

Dermatological:

Blood Pressure:



I hereby certify that I am a licensed state examiner and have examined the above named individual and understand that he/she will be involved in participating in BTYFL football. I hereby swear and attest that this individual is physically fit and I have found no medical reason which would prevent this individual from safely participating in BTYFL activities for the 2013 season. I am therefore clearing this individual for athletic participation without limitation.

Please place medical professional stamp here or fill out the following:

Signed _______________________________________________ Date ________________________________________

Print Name ________________________________________________________________________________________

Please indicate medical profession (M.D., D.O. R.N., etc.) ___________________________________________________

Address ________________________________________ City __________________________ State _______________

Telephone ______________________________ Fax Number ________________________________________________


Section II must be completed in its entirety ONLY by a Licensed State Examiner (medical doctor, nurse practitioner, etc., this may vary by state). NO other forms are acceptable unless Section II is modified or substituted ONLY to comply with local and/or state laws or because of medical practitioner regulations (i.e. the medical practice insist on its own form). In either case, Section I must still be filled out entirely and attached to the modified/substituted form.