Swiffers Track Club – Athlete Physical Form

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Athlete Information:
Full Name: ____________________________________________________
Date of Birth: ________________________________________________
Address: _____________________________________________________
City: ________________________ State: ________ ZIP Code: _______
Email Address: _______________________________________________
Phone Number: ______________________________________________
Emergency Contact Name: ____________________________________
Emergency Contact Phone Number: ___________________________

Medical History:
Please provide accurate and complete information regarding the athlete’s medical history, including any allergies, chronic conditions, or previous injuries. This information is essential for ensuring the safety and well-being of the athlete during club activities.

Medical Conditions: ___________________________________________

Allergies: __________________________________________________

Medications: _______________________________________________

Previous Injuries: ___________________________________________

Physician Information:
Please provide the contact details of the athlete’s primary physician.

Physician’s Name: __________________________________________

Clinic/Hospital Name: _______________________________________

Phone Number: ______________________________________________

Insurance Information:
Please provide the details of the athlete’s primary insurance coverage.

Insurance Provider: _________________________________________

Policy/Group Number: ______________________________________

Emergency Consent:
In the event of a medical emergency where immediate treatment is required, I hereby give permission for the Swiffers Track Club staff or any assigned medical personnel to seek and administer appropriate medical attention to the athlete.

Parent/Guardian Signature: _________________________________

Date: ______________

Physical Examination:
Each athlete is required to undergo a physical examination to ensure their readiness and fitness for participation in on-field activities. Please schedule a comprehensive physical examination for the athlete with their primary physician.

Physician’s Notes:
The physician should complete the following section based on the athlete’s physical examination results.

Height: _________________________ Weight: ________________________

Blood Pressure: __________________ Resting Heart Rate: ______________

Vision: _________________________ Hearing: _______________________

General Medical Evaluation: ______________________________________

Cardiovascular Health: ___________________________________________

Musculoskeletal Evaluation: _______________________________________

Clearance for Participation:
Based on the physical examination results, the athlete is:
___ Cleared for full participation in all Swiffers Track Club activities.
___ Cleared with restrictions (Please specify restrictions): _______________
___ Not cleared for participation at this time (Please explain): ____________

Physician’s Name (Printed): _____________________________________

Physician’s Signature: ________________________________________

Date: ______________

Thank you for completing the Athlete Physical Form. Please submit this form to the designated club representative before the athlete can participate in any on-field activities. The information provided will be treated with utmost confidentiality and used solely for the purpose of ensuring the athlete’s safety and well-being during club activities.

Download Now Athlete Physical Form