Pop Warner Little Scholars, Inc.

2009 PHYSICAL FITNESS & MEDICAL HISTORY FORM

Special Note: This form must be dated after January 1, 2009 and then submitted to your LOCAL Pop Warner organization. No other forms are acceptable unless Section II is modified or substituted ONLY to comply with local and/or state laws or because of medical practitioner regulations (i.e. the medical practice insists on its own form). In either case, Section I must still be filled out entirely and attached to the modified/substituted form. Section II must be completed in its entirety ONLY by a Licensed State Examiner (medical doctor, , nurse practitioner, etc.) Section I: FOR PARENT/GUARDIAN COMPLETION ONLY

Legal Name of Participant (must match birth certificate):

Last _____________________________First_________________Middle___________________ Address:__________________________________________________ City:_____________________________State: ______Zip:__________ Telephone No:_________________________ Date of Birth: _________________________ Male__ Female __ Name of Primary Medical Insurance Company:_______________________________ Policy Number: _____________________Membership Number:_________________ Name of Primary Insured: ________________________________________________________ Sport (check one): Cheer__ Dance__ Tackle__ Flag__

PARTICIPANT MEDICAL HISTORY

  1. Are there any injuries requiring medical attention? Yes No
  2. Are there any past surgeries or scheduled surgeries? Yes No
  3. Is the participant currently under the care of a medical practitioner? Yes No
  4. Is the participant currently taking any medications? Yes No
  5. Does the participant have any allergies (penicillin, bee stings, etc)? Yes No
  6. Does the participant have asthma/require the use of an inhaler? Yes No
  7. Is the participant diabetic/require medication for diabetes? Yes No
  8. Does the participant currently require medication ? Yes No
  9. Does/has the participant have/had seizures? Yes No
  10. Does the participant wear glasses or contact lenses? Yes No
  11. Does the participant wear a brace or other medical support device? Yes No
  12. Does the participant have any other physical limitations or

medical conditions? Yes No If you answered yes to any of the above questions, please provide the question number and an explanation in the following space:

I hereby certify that this information is accurate to the best of my knowledge. I understand that this medical authorization may be voided in the event of injury, illness or accident and my child may not be cleared for participation at such time. Furthermore, I hereby acknowledge that it is my responsibility to inform my child’s coach or organization official in writing if there is any change in the medical condition of my child. I also understand that it’s my responsibility to obtain written permission from my child’s physician on official medical stationary in order to seek permission for my child to resume participation after any and all such injury, illness or accident.

Signature of Parent or Legal Guardian: ______________________________________________

Print Name_____________________________________________________________________

Relationship to Participant_________________________________________________________

Dated___________________________________________________________________________

1/16/2009

Pop Warner Little Scholars, Inc.

Section II: THIS SECTION IS TO BE COMPLETED ONLY BY A MEDICAL PROFESSIONAL

Name of Participant:__________________________________________ (Please check the following if healthy or note otherwise):

Height Weight Eyes
Ears Mouth Nose & Throat
Respiratory Cardiovascular Neurological
Muskoskeletal Dermatological Blood Pressure

I hereby certify that I am a licensed state examiner and have examined the above named individual and understand that he/she will be involved in participating in Pop Warner football, cheer or dance programs. I hereby swear and attest that this individual is physically fit and I have found no medical reason which would prevent this individual from safely participating in Pop Warner activities for the 2009 season. I am therefore clearing this individual for athletic participation without limitation.

Please place medical professional stamp here or fill out the following:

Signed_____________________________________________ Date:____________________ Print Name__________________________________________ Please indicate medical profession (M.D., D.O. R.N., etc.)______________ Complete this section or the medical professional’s stamp may be placed below. Address___________________________City______________________State_________ Telephone ___________________________________ /Fax Number: ______________________

Section II must be completed in its entirety ONLY by a Licensed State Examiner (medical doctor, nurse practitioner, etc. – this may vary by state). NO other forms are acceptable unless Section II is modified or substituted ONLY to comply with local and/or state laws or because of medical practitioner regulations (i.e. the medical practice insists on its own form). In either case, Section I must still be filled out entirely and attached to the modified/substituted form.

1/16/2009