Intercollegiate Athletics Policy Manual

4.00 Camp Policy Manual

APPENDIX - Medical 15.30.8 Clearance Physical Examination

THE UNIVERSITY OF TEXAS AT AUSTIN
University Sponsored Summer Sports Camps
Departments of Intercollegiate Athletics for Men and Women

PRE-ACTIVITY CLEARANCE EXAMINATION:
PHYSICIAN AUTHORIZATION

 

Participant’s Name

Camp

I hereby certify that I have examined the above named patient and have found him/her fit to attend and participate in the University Sponsored Summer Sport Camps.  I know of no impairments, which would limit his/her participation in all camp activities except those that I have listed below.  I further certify that he/she is free from any and all contagious diseases.
Restrictions and/or Comments   
 
 
 
 
 

Date of Physical Examination (must have been completed within the last 12 months) 
 

Physician's Signature 
Address 
City/St./Zip 
Phone 

 

last updated: February 11, 2009