03 MEDICAL CLEARANCE FORM

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MEDICALLY DIRECTED PROGRAMS

MEDICAL CLEARANCE FORM

Date:

A BRIEF EXPLANATION

Dear Physician:
The program is specifically designed to address
The facility’s priority is safe exercise for all participants. All participants must complete a standard PAR-Q (Physical Activity Readiness Questionnaire), a Pre-Program Assessment, an Informed Consent, and must have their primary physician provide written approval to participate.

FOR YOUR INFORMATION:

CLEARANCE:

Physician – Please INITIAL the appropriate box to indicate your approved clearance for this individual to participate in the medically directed fitness program described above.:
MM slash DD slash YYYY
(Note: When signing digitally, once you type your name it will be saved in a cursive font, and that shall be considered valid and legally binding as if you had physically signed it by hand.)