Sports Participation Medical Clearance Form
Participant Information
Full Name
Date of Birth
Sport
School / Organization
Medical History
Relevant medical conditions or allergies
Medications currently being taken
Past injuries or surgeries
Physical Examination
Height
Weight
Blood Pressure
Heart Rate
Examiner’s notes
Medical Clearance
Cleared for full participation in sports
Not cleared (specify limitations/reasons below)
Examiner’s Signature
Date
Parent/Guardian Signature (if under 18)
Date