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