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J.A.A.F.S.C. 
Medical Examination Form Season 20__

This form satisfies Section IV of the Player's Season Contract.  Must be completed by a qualified Doctor of Medicine, Doctor of Osteopathy, Nurse Practitioner or Physicians Assistant as described in Rules, Article III, Section C., Certification #3.

J.A.A.F.S.C. Chapter:  Yucaipa          Team Name:  T-Birds
Last: First: MI:
Phone: DOB: Age:
Address:
City: State: Zip:
Height: Weight: Blood Pr:
Heart:    Ears:   
Nose:    Teeth:   
Abdomen:    Extremities:   
Hernia:   
Remarks:                                                                              

                                    



* Place Dr. Stamp above *

______		 While this examination does not constitute a complete Medical Examination, it does on this date,
and based upon my observations, meet the requirements for participation in this youth football program.

______		 The above individual examined by me on this date is considered not physically qualified to participate in this youth football program for the following reason(s):
Examining Doctor:
Office Phone: Date: