Santa Barbara Youth Football League
Medical Release / Health Screen
SBYFL Medical Release / Health Screen
Page 1 of 2
All participants must be screened and cleared by a medical doctor before s/he may begin practice. Participants may be
screened by their own physician or pediatrician.
Participants Name
Date of Birth
Address
Height
Weight
City
Zip
List all childhood illnesses, both past and ongoing:
List all operations and hospitalization dates:
Has Participant ever had a concussion or other head injury?
YES
NO
Has Participant ever broken, sprained or seriously twisted a joint or limb?
YES
NO
Has participant ever had (circle all that apply):
Anemia
Arm Pain
Asthma
Breath Shortness
Cancer
Chest Pains
Childhood R.A.
Chronic Cough
Constipation
Dental problems
Depression
Diabetes
Diarrhea (Recurring)
Dizziness / Lightheadedness
Ear Noises
Ear Pain
Epilepsy
Fainting
Genital Pain
Gum problems
Headaches (Chronic)
Hearing Loss
Heart Beat (Irregular)
Heartburn (Recurring)
Hernia
Hypoglycemia
Incontinence
Irritability before meals
Lack of Coordination
Leg Pain
Light Headed before Meals
Liver Problems
Low Blood Pressure
Lower Back pain
Memory Loss
Mood Swings
Nausea (Recurring)
Neck pain
Nose Breathing Difficulty
Nose Bleeds
Painful Urination
Pneumonia
Rheumatic Fever
Skin Problems
Sore Throats (Frequent)
Speech Difficulty
Spitting up Phlegm
Spitting up Blood
Stomach Pain (Recurring)
Tingling of Hands and feet
Tuberculosis
Vision Problems
Vomiting
Weight Loss or Gain (Dramatic)
SBYFL Medical Release / Health Screen
Page 2 of 2
Please briefly explain and circled items on Page 1 (one):
Is there family history of health problems (parents, grandparents, brothers or sisters)? If yes, please explain:
Parent / Legal Guardian Release:
I am the Parent / Legal Guardian of the child listed on this Medical Release / Health Screen Form. I have now knowledge
of any impairment or condition that would prevent my child’s participation in a youth football program.
Print – Parent/Legal Guardian
Signature – Parent/Legal Guardian
Date
Physician Use Only – Please do not write below this line
Physician Release
Based on my Examination and the information provided by this Medical Release / Health Screen Form:
I release this child to participate in a youth tackle football program.
I do NOT release this child to participate in a youth tackle football program, and refer this child for further
consultation with his family physician or other specialist.
Print – Examining Physician’s Name
Signature – Examining Physician’s Name
Place Office Stamp Here
Date