Performing Arts Student Medical Clearance Form
Student Information
Full Name
Date of Birth
Student ID
Grade/Year
Program/Course
Emergency Contact
Contact Name
Contact Phone
Relationship to Student
Medical History
Please list any medical conditions or allergies
List any medications currently prescribed
Physical or activity restrictions (if any)
Physician's Clearance
Physician Name
Facility/Practice
Phone Number
Clearance: Student is medically cleared to participate in performing arts activities
Yes
No
Conditional
Comments or Restrictions
Physician Signature
Date