Medical Clearance Form for Marathon Runners
Participant Information
Full Name
Date of Birth
Gender
Male
Female
Other
Contact Number
Address
Emergency Contact
Emergency Contact Name
Relationship
Contact Number
Medical History
Allergies
Current Medications
Chronic Illnesses (e.g., asthma, diabetes)
Previous Surgeries or Hospitalizations
Other Relevant Information
Physician's Assessment
Physical Examination Findings
Is the applicant fit to participate in a marathon?
Yes
No
If not, please specify reasons or restrictions:
Physician's Information
Physician Name
License Number
Signature
Date