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Medical Release for Return to Athletic Participation Following a Head, Neck Cervical Column Examination
Student's Name:
*
First
Last
Student's School:
*
Date of Examination
*
MM
/
DD
/
YYYY
Time of Examination
*
HH
:
MM
AM
PM
AM/PM
Athlete:
*
Please select
Is UNABLE to return to any participation in athletics until further notice
May RETURN TO FULL participation in athletics
Licensed Health Care Provider's Name:
*
First
Last
Licensed Health Care Provider's Phone:
*
###
-
###
-
####
Wrestling Official's Name:
*
First
Last
Wrestling Official's Phone:
*
###
-
###
-
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Date:
*
MM
/
DD
/
YYYY
Signature
*
Clear
