Medical Clearance Form for Cyclocross Racers
Racer Information
Full Name
Date of Birth
Gender
Team/Club (if applicable)
Emergency Contact Name & Relationship
Emergency Contact Phone
Medical Provider Section
Date of Examination
Significant Medical Conditions
Current Medications
Allergies
Activity Limitations/Recommendations
Medical Clearance
Cleared for full participation in cyclocross racing.
Not cleared. Reason(s):
Provider Name
Signature
Date