Medical Information Form

Orange County Youth Football League Cornwall – Goshen- Highland - Kingston – Marlboro – Middletown – Minisink Valley – Monroe – Monticello – Newburgh – City of Newburgh – Pine Bush – Port Jervis – - Valley Central – Wallkill – Warwick – Washingtonville
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:
Revised 2-24

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: