Summer Swim Team Pre-Participation Physician Clearance
Athlete Information
Athlete Name
Date of Birth
Parent/Guardian Name
Emergency Contact Number
Medical History
Asthma
Diabetes
Seizures
Heart Condition
Allergies
Other
If Other, please specify:
List medications currently taken:
Physician Assessment
This is to certify that I have examined the above-named athlete and found that:
Athlete is cleared for participation in all swimming activities
Athlete is cleared with the following restrictions:
Athlete is NOT cleared for participation
Physician Information
Physician Name
Phone Number
Signature
Date