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New Canaan Youth Football Medical Form & Doctor Certification

2021

Player’s Name: __________________________

Age: __________

Grade (Fall 2021): ____________

School (Fall 2021): __________________________

DOCTOR CERTIFICATION

I have examined_____________________ and find him/her physically

fit to play tackle football.

____________________________________________

Any additional comments:

PHYSICAN’S SIGNATURE: ________________________

DATE: ______________

PHYSICAN’S NAME: _____________________________

PRINT OR STAMP

MEDICAL INFORMATION (to be completed by parent)

Allergies: Yes __________ No __________

If yes, what________________________________

Medication________________________________

Chronic Conditions Yes ________No___________

If yes, what________________________________

Additional information: