LINDEN YOUTH LIONS FOOTBALL & CHEERLEADING

PHYSICAL MEDICAL EXAM AND PARENTS CONSENT FORM

*This area to be completed by parent or guardian of the participant*

Name of participant:

Date of birth:

Name of person to notify in case of an emergency:

Address:

Emergency phone:

Home phone:

Insurance Carrier:                                                                                             Insurance Group#

Has the participant named above had any injuries or physical conditions that should be watched?

If, yes please list:

I /We, the undersigned, parent/guardians of___________________________________________

A minor, hereby authorize a representative of Linden Youth Football League, Inc. as agents for the undersigned to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of the medical practice art on the medical staff of an accredited hospital, whether such diagnosis or treatment is rendered at the office of the said physician or at said hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, but is given to provide authority and power on the part of our aforesaid agent to give specific consent to any and all such diagnosis, treatment, or hospital care which the aforementioned physician in the exercise of his best judgment may deem advisable. This authorization shall remain effective until_______, unless sooner revoked in writing delivered to said agent.

Parent/Guardian Signature:______________________________________date:_____________

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THIS AREA TO BE COMPLETED BY LICENSED PHYSICIAN

Weight:____________ Height:______________ Blood Pressure:_____________

Is the said participant listed above able to participate in youth tackle football, or youth cheerleading?_________ Football_____ Cheer______

Additional comments:________________________________________________________________________

Please print name of doctor:____________________________________________License #:______________

Address:________________________________________________________________Phone:____________

Signature of Doctor:__________________________________________________________Date:___________