CENTER JR. COUGARS
FOOTBALL & CHEER

2008 Medical Clearance Form
                                                                    
All physicals must be completed between April, 2008 and August 1, 2008.

This form is to be completed, signed by a physician and submitted to the
Center/Antelope Jr. Cougars no later than the first day of practice.

Players and Cheerleaders will not be able to begin practice without a Medical
Clearance Form on file with CAJC.

Child’s Name: __________________________________________________

Date of Birth: ___________________  Weight: ________________________

This examination does not constitute a complete medical examination, it does
however, based upon my observations on the below date, meet the requirements
for the above named child to participate in the following sport:

Tackle Football: ____Yes ____ No                   Cheerleading: ____ Yes ____ No

Any known allergies? ____ Yes ____ No
If yes, please describe: ___________________________________________

Any limitations? ____ Yes ____ No
If yes, please describe: ___________________________________________

Remarks:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

Physician Signature: ____________________________ Date: ____________

Physician’s OFFICE Stamp required here: (Name, Address and Telephone
Number)



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