Football Medical Physical

This form must be completed and returned prior to GYFl practice. Physical must be within 365 days from first day of football practice (Contact regional General Manager for GYFL Fall practice date in August, 2016, or GYFL Spring practice date in April, 2017).

To be completed by parent:

Name____________________________________________________ Age_______ Address______________________________________________________

City _______________________ State___________ Zip Code _______________

Date of Exam__________________

Please indicate which camp location attending_______________________________________

Insurance

Name of Major Medical Insurance Company _________________________________________________________________________________

Policy Number ______________________________

State __________

Name of Holder______________________________________________

To be completed by physician or attach copy of school exam:

Height_______ Appearance_____________________________________________________

Weight_______Skin___________________________________________________________ B/P_________ Respiratory_____________________________________________________

Pulse________ Cardiac_________________________________________________________

Detail limitations, conditions, or regular medication (OTC or RX) ____________________________________________________________________________

____________________________________________________________________________

I have recently examined the above named athlete and find him to be in good physical condition and fully able to participate in the activities of the Grassroots Youth Football League for the 2016/17 season.

Physician’s Signature ________________________________ Date ______________, 2016