2010 PHYSICAL FITNESS & MEDICAL HISTORY FORM
Special Note: This form must be dated after January 1, 2010 and then submitted to Bennett Youth Dance

Section I must still be filled out entirely and attached to the modified/substituted form. Section II
must be completed in its entirety ONLY by a Licensed State Examiner (medical doctor, nurse practitioner, etc.)

Section I: FOR PARENT/GUARDIAN COMPLETION ONLY
Legal Name of Participant (must match birth certificate):

Last: First: Middle: _____________________________________________________________________

Address: ____________________________________________________________________________

City: State: Zip code: ___________________________________________________________________

Telephone No.: Cell Phone No.: __________________________________________________________

Date of Birth: Male Female ______________________________________________________________

Name of Primary Medical Insurance Company: _______________________________________________

Policy Number: Membership Number: ______________________________________________________

Name of Primary Insured: _______________________________________________________________

Sport (check one): Cheer: Dance:

PARTICIPANT MEDICAL HISTORY
1 Are there any injuries requiring medical attention? Yes No
2 Are there any past surgeries or scheduled surgeries? Yes No
3 Is the participant currently under the care of a medical practitioner? Yes No
4 Is the participant currently taking any medications? Yes No
5 Does the participant have any allergies (penicillin, bee stings, etc)? Yes No
6 Does the participant have asthma/require the use of an inhaler? Yes No
7 Is the participant diabetic/require medication for diabetes? Yes No
8 Does the participant currently require medication ? Yes No
9 Does/has the participant have/had seizures? Yes No
10 Does the participant wear glasses or contact lenses? Yes No
11 Does the participant wear a brace or other medical support device? Yes No
12 Does the participant have any other physical limitations or medical conditions? Yes No

If you answered yes to any of the above questions, please provide the question number and an explanation in the
following page:

"I hereby certify that this information is accurate to the best of my knowledge. I understand that this medical authorization may be voided in the event of injury, illness or accident and my child may not be cleared for participation at such time. Furthermore, I hereby acknowledge that it is my responsibility to inform my child’s coach or organization official in writing if there is any change in the medical condition of my child. I also understand that it’s my responsibility to obtain written permission from my child’s physician on official medical stationary in order to seek permission for my child to resume participation after any and all such
injury, illness or accident."

Signature of Parent/Guardian: ______________________________________________________________

Print Full Legal Name: ___________________________________________________________________

Relationship to Participant: ________________________________________________________________

Date: ________________________________________________________________________________