Medical Information Form

Town: _____________________________________     Division: _____________

All football players and cheerleaders need a note or this form filled out from their own doctor to participate in the program.

ORANGE COUNTY YOUTH FOOTBALL & CHEERLEADING LEAGUE RULE:
No child will be allowed to practice without this form completed or a note from a doctor giving your child permission to practice football or cheerleading.

**PLEASE LIST ANY ADDITIONAL ALLERGIES OR PHYSICAL CONCERNS THAT WE NEED TO KNOW ON THE BOTTOM OF THIS FORM

Player Name: ______________________________________________________________

Date of Birth: ______________________________________________________________

Address: ___________________________________________________________________

Telephone: _________________________________________________________________

TO BE COMPLETED BY Medical Provider

Name of Medical Provider: _________________________________________ Phone Number: ___________________

Allergies: __________________________________________________________________________

Physical or emotional concerns: __________________________________________________

____________________________________________________________________________________

This child is in good health and may participate in football / cheerleading for the 2024 season.

Signature of Physician: ______________________________Date: _______________________

Physician Stamp: