CCS Sports Medical Form (option 3) | Page 2

This form must be completed and signed by a physician on or after July 1 st, entering each school year. Student Name: ________________________________________

Date of Birth: ___________________

This student is planning to participate in athletics at The Cornerstone Christian School. Please complete this form to confirm that the student can safely participate.

Date of Student’ s last physical examination: _________________________________

I certify that I have examined the above student and recommend him as being able to compete in supervised athletic activities as listed below.

BASKETBALL SOCCER VOLLEYBALL SKIING ALL SPORTS

Reservations or Accommodation Recommendations: _____________________________________________________________________________________________

____________________________________________________________________________________________

Date: ____________

Signature of Examining Physician: ___________________________________________

Physician Name( printed) and Office Address:

______________________________________________________________________________________