Physician’s Certification

Physician’s Certification
This is to certify that I have made a complete physical examination of
______________________. I have determined from this physical examination that the
aforementioned person is in good physical condition and is capable of participating in the
strenuous exercise examination which is listed on the previous page. This examination is given
by Edinboro University of Pennsylvania to persons who have applied for positions within the
Facilities Department or the Office for Students with Disabilities.
Medical Examiner Signature: _______________________________ Date: _______________
Medical Examiner Printed Name: ________________________________
Release from Liability
I, __________________________ hereby release Edinboro University of Pennsylvania,
Keystone Rehabilitation Systems, University agents, representatives and employees from any
liability for injuries incurred or illness resulting from participating in the Physical Agility Test
for applicants of Edinboro University of Pennsylvania. It is understood that the test is one of
stamina and to the best of my knowledge, I am in good physical condition and capable of
participating in this test. This release is my choice, and is an alternative to a physical
examination that I have been asked to perform.
Applicant Signature: _____________________________________ Date: _________________
Applicant Printed Name: _______________________________________
Witness: _______________________________
Witness: _______________________________
One of the 14 universities in Pennsylvania’s State System of Higher Education