Medical Clearance Form

Youth Baseball Players

Player Name

Date of Birth

Age

Parent/Guardian Name

Parent/Guardian Contact Info

List any allergies

Current medications

Relevant medical conditions

Does the player require any special accommodations? Yes No

If yes, please explain

Physician Name

Physician Phone

Date of Examination

Based on the examination and history, the above named player is medically cleared to participate in baseball activities.

Physician Signature

Date