1. No category

PACIFIC YOUTH FOOTBALL LEAGUE
PLAYER AND CHEERLEADER PHYSICAL FORM
SEASON: ____2015____
SECTION 1:
CHAPTER: ____________________
PHYSICAL DESCRIPTION & CONDITION
PARENT TO COMPLETE THIS SECTION
NAME OF PARTICIPANT: __________________________________________________________________
HEIGHT: ____ FT. ____ IN.
SECTION 2:
WEIGHT: _______ LBS.
HEALTH HISTORY
PARENT TO COMPLETE THIS SECTION
NAME OF PHYSICIAN:
PHONE:
PREFERRED EMERGENCY CENTER:
CITY:
LIST CURRENT MEDICATIONS:
SECTION 3:
HAIR COLOR: ________ EYE COLOR: _________
MEDICAL EXAM
RECORDED HEIGHT:
RECORDED WEIGHT:
RECORDED BLOOD PRESSURE:
RECOREDED TEMPURATURE:
CIRCLE CURRENT PROBLEMS:
ASTHMA
DIABETES
HEAD INJURIES
HEAT STROKE
HEART CONDITION
KIDNEY INJURIES
SHOULDER/HIP INJURIES
OTHER:
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
DOCTOR TO COMPLETE THIS SECTION
EARS
EYES
NOSE
TEETH
HEAD/NECK
HEART
LUNGS
SKIN
HERNIA
ADBODMEN
EXTREMIITIES
FEET
OTHER:
[__]
WHILE THIS EXAM DOES NOT CONSTITUTE A COMPLETE MEDICAL EXAMINATION, IT DOES ON THIS DATE, ON MY
OBSERVATIONS, MEET THE REQUIRMENTMENTS FOR PARTICIPATEION IN THE YOUTH FOOTBALL PROGRAM.
THE INDIVIDUAL EXAMED BY ME ON THIS DATE IS CONSIDERED “NOT” PHYSICALLY QUALIFIED TO PARTICIPATE IN THE
YOUTH FOOTBALL PROGRAM FOR THE FOLLOW ING REASONS:
[__]
EXAMINED BY:
SIGNATURE:
NAME OF FACILITY:
DATE:
PHONE:
STAMP OF OFFICE
DO NOT USE THIS SPACE
THIS SPACE TO REMAIN BLANK
FOR PYFL CERTIFICATION
2015 PYFL Physical Form