Adaptive Sports Event Medical Clearance Form
Participant Information
Full Name
Date of Birth
Address
Phone
Email
Emergency Contact
Name
Phone
Relationship
Medical Information
Primary Diagnosis / Disability
Current Medications
Allergies
Relevant Medical History
Event Details
Event Name
Event Date(s)
Sport(s) Participating In
Physician Section
Cleared for full participation?
Yes
No
Limited
If Limited, please specify restrictions
Physician Name
Signature
Date