2023-24 Ppe
2023-24 Ppe
2023-24 Ppe
05. 06. 20
11. When was your last tetanus shot? Month ______Date ______Year_______
14. Please feel free to ask the doctor to address any questions/concerns that you have_______
____________________________________________________________________________
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and
correct.
Student Signature:___________________ Parent Signature:______________________ Date_________
Student Name:______________________ DOB:__________ Grade:______ ID:____________
*If conditions arise after the athlete has been cleared for participation, the physician may rescind the
clearance until the problem is resolved and the potential consequences are completely explained to the
athlete. In the event that the student-athlete should be afflicted with a condition after initial clearance, the
individual may require additional clearance paperwork be turned into the athletic trainer.*
**Screenings may only be performed by licensed MD, DO, PAC, and NP.**
***Physicals must be completed after 6/1/23***