Medical Clearance Form for Youth Soccer Players

Player Full Name: Date of Birth: Parent/Guardian Name: Parent/Guardian Contact Number: Team Name (if applicable):

Health History / Present Illness (if any):

Current Medications:

Known Allergies:

Recent Injuries or Surgeries:

Physician Statement:

This participant has been examined and is medically cleared to participate in soccer activities, practices, and games unless indicated otherwise.

Restrictions/Notes (if any):

Physician Name

Physician Signature

Date