PHYSICIAN’S STATEMENT

I hereby certify that ________________________________________ is in good health and physically able to participate in interscholastic athletics including contact sports. This certificate is valid for the school year 2007-2008 unless voided by any serious injury or illness.

I have listed below any known conditions, illnesses or prior injuries, which could affect participation in sports and/or medical treatment.

Interscholastic sport(s) that this student cannot participate in are:

PHYSICIAN’S NAME (Please Print): ________________________________________

PHYSICIAN’S SIGNATURE _______________________________________________

DATE ________________________________________________________________

STUDENT’S NAME ________________________________________GRADE_______