UTSA Spirit FAQ
Q: What is the name of the danceteam, cheerleaders and mascot?
A: Chaparelle Danceline, Cheerleaders and Rowdy the Roadrunner (Lil’ Rowdy and Big Papa)
Q: How can I get more up to date information about the UTSA cheerleading squad & Chaparelle Danceline tryouts?
A: The best way to receive the most up to date information is to log on to the following pages: www.goutsa.com and
www.myspace.com/utsaspirit or call (210)458-4164
Q: What are the sizes of the teams?
A: Co-ed cheerleading team not to exceed 30 (no set number of males and females) and Chaparelle danceline can
have up to 20 members
Q: Do you offer scholarships?
A: Scholarships are available for returning members 1st. New members are eligible for scholarships once they have
completed a full semester at UTSA and amount earned is based upon grade point average and team participation.
Q: What type of hours are dedicated to the program each week?
A: Practice and work-out hours are up to 15 hours a week not including games. Each team practices 3 days a week.
Cheerleaders have a mandatory team tumbling class once a week.
Q: Since UTSA does not currently have football, what do sports do you cheer/dance for?
A: We cheer/dance at all home men and women’s basketball and volleyball games.
Q: What are my financial obligations?
A: Cheerleaders and Dancers will have to pay for camp, practice attire and nationals. There are several
fundraisers available but we are always looking for sponsorships and donations to help reduce personal cost.
Q: Do I need an invitation to attend a tryout session?
A: No! All you have to do is mail in your completed tryout application (including the physical) and your application
fee to the spirit office. The mailing address is:
UTSA Spirit Program
Attn: Melissa R. Martinez
One UTSA Circle
San Antonio, TX 78249
Q: If I can’t make it to tryouts, can I send in a video tape?
A: There are 2 tryout dates. If you still can not make them please contact coach to see what other options are
available.
Q: When and where are tryouts?
A: Tryouts are typically held late April and early May and are a 2 day process. Tryouts are held in the Recreation
& Wellness Center and/or PE Building which is located at the 1604 campus.
Q: What are the minimum requirements to tryout for the UTSA cheerleading team?
A: Girl’s tumbling: Standing: back tuck Running: Round off back handspring back tuck.
Girl’s stunting: Flyers: One-legged stunts (all variations), full and double downs, etc.
Bases: Advanced knowledge of all positions (main, side and back spot)
Boy’s tumbling (preferred): standing backtuck
Boy’s stunting: toss extension, one-legged stunt (group stunt also a plus)
Q: Is there a height and weight requirement?
A: We do not have a height and weight requirement but we do require all members to maintain a good physique in
order to participate in such a demanding sport. Body fat is tested before tryouts and throughout the year.
Q: Will there be mats to tumble and stunt on during tryouts?
A: For safety, we always practice on mats, especially when attempting new skills. For tryouts, we will have mats
out so we can safely stunt and help eliminate the risk of anyone being injured during the tryout process. However,
since our primary sport is basketball, anyone who is attempting skills that consist of a layout or below will be asked
to tumble on gym floor without mats and all basic stunts will be done on gym floor.
Q: When are mascot tryouts held?
A: Anyone interested in mascot must contact the coach. We have up to 3 people to help cover all the games and
appearance required of Rowdy throughout the year. Mascots appearances are year round.
Q: When and where is cheer camp?
A: The UTSA Cheerleaders attend a mandatory NCA collegiate camp every summer at SMU in Dallas, TX. Camp is
typically in the latter part of July but summer practice starts as early as June. Dancers do not attend a
mandatory camp. An optional camp is provided. However practices will begin as early as July.
Q: When can I take summer school?
A: It is best to take the 1st summer session to not interrupt practices and camp during 2nd session.
Q: When can I take a vacation?
A: There will be a weekend practice June 20 & 21. Practices will begin July 19-camp. Practices will begin August
17th. These dates could possibly change after the team is chosen.
Q: When do we get off for Spring Break?
A: Spring break varies year to year due to competition or the Southland Conference Basketball Tournament. Do
not make plans until dates for practice or SLC Tournament have been set.
Q: Do the UTSA cheerleaders or Danceline compete at nationals?
A: Competition is determined by team size and coaches review. We attend the NCA/NDA Collegiate Nationals in
Daytona Beach, FL in April.
Q: Can I just be part of the competition squad?
A: No. Competition team is chosen from the current team and tryout for the team will be by invitation only.
Q: Who runs practices?
A: All practices are run by Coach, Strength & Conditioning Coach and captains.
Q: Where do I go if I have a problem with the team? If I have a personal problem?
A: You must approach your captains and/or Coach if you have any problems or concerns. Coach has final decision
on everything. Should you have a personal problem and you can not approach your coach, UTSA provides on campus
counselors.
Q: How can I book a cheerleader and/or Rowdy the Roadrunner appearance?
A: You must fill out and return a completed UTSA Spirit Program Request for Appearance/Performance form. Call
the office at (210) 458-4164 or email Melissa Martinez at melissa.rodriguez1@utsa.edu.
CHAPARELLE DANCELINE INFORMATION
The Chaparelle dance line is a 12-20 member team that performs at volleyball, men’s and
women’s basketball games, attend soccer games, school functions and a few outside
appearances. Competition varies from year to year and not a priority. Competition is the NDA
Collegiate Championships in Daytona Beach, FL.
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•
•
•
•
There are 2 dates in which a dancer may choose to audition: April 25 & 26 or May 1 & 2.
Any dancers trying out for the spirit program must apply to UTSA and be accepted to tryout.
Members are required to maintain a 2.0 GPA. You must take all necessary tests for admission.
For information call the admissions office (210) 458-4530 or www.utsa.edu
All applicants are required to return the tryout packet: Application, release, information sheet,
medical history, physical examination, insurance form, emergency contact form, a front and back
copy of your insurance card, a recommendation letter from current coach, a $15 application fee, 2
pictures (a head shot & full body shot) in sportsbra and hot pants (4x6 only) by Wednesday, April
17th. This will be non-returnable and used for identification purposes only. Checks, money orders,
and credit cards will be accepted. Please make checks payable to: UTSA Spirit - Dance.
Any part of tryout requirement not turned in on time will result in non-tryout.
All material for the tryouts will be taught during the 2 day process. Please be sure to wear
business attire for interview. (times will be set as applications arrive)
2009-2010 members will be announced after the 2nd tryout. You will be contacted by email and
posted on both websites by May 8th. Should you make the team you must contact the coach
immediately to accept your position. If you have not made contact by May 15th your position will
not be guaranteed.
For further questions please read the FAQ.
TRYOUTS ARE CLOSED TO THE PUBLIC! NO FAMILY OR FRIENDS ALLOWED!
Requirements:
rt. & left leaps
switch leaps
double/triple pirouettes
toe touch
fouette turns
axle turns kicks
chaine & pique turns
Girls must wear a sportsbra (not a tank top), hotpants (biker shorts), dance shoe, hair accordingly, no
jewelry or gum. All tattoos must be covered.
Practices:
Practices will consist of skills, learning new material and strength and conditioning
$ Expenses (dance)
Optional: Camp (Prodance) will be held in Houston, TX July 29 – Aug. 1st. Prodance is a procamp that
caters to NBA, NFL, CFL, WNBA, etc. We are one of the few collegiate programs with a formal
invitation. Camp is $385 (meals & hotel not included). If you are interested please contact me for
further details once you have been selected.
Competition: Competition is a privilege and does not happen every year. Possible $900 trip.
*attire costs coming soon*
CHEERLEADER INFORMATION
The UTSA cheerleaders are a 16-30 member team (consists of males and females) that cheer
at volleyball, men’s and women’s basketball games, school functions and a few outside
appearances. Competition varies year to year. Should we compete competition is the NCA
Collegiate Nationals in Daytona Beach, FL.
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•
•
•
•
•
•
There are 2 dates in which a cheerleader may choose to audition: April 25 & 26 or May 1 & 2.
Any cheerleaders trying out for the spirit program must apply to UTSA and be accepted to
tryout. Members are required to maintain a 2.0 GPA. You must take all necessary tests for
admission. For information call the admissions office (210) 458-4530 or www.utsa.edu
All applicants are required to return the tryout packet: application, release, information sheet,
medical history, physical examination, insurance form, emergency contact form, a front and back
copy of your insurance card, a recommendation letter from current coach, a $15 application fee, 2
pictures (a head shot & full body shot) in sportsbra and hot pants (4x6 only) by Wednesday, April
17th. This will be non-returnable and used for identification purposes only. Checks, money orders,
and credit cards will be accepted. Please make checks payable to: UTSA Spirit - Cheer.
Any part of tryout requirement not turned in on time will result in non-tryout.
All material for the tryouts will be taught during the 2 day process. Please be sure to wear
business attire for interview. (times will be set as applications arrive)
2009-2010 members will be announced after the 2nd tryout. You will be contacted by email and
posted on both websites by May 8th. Should you make the team you must contact the coach
immediately to accept your position. If you have not made contact by May 15th your position will
not be guaranteed.
For further questions please read the FAQ.
TRYOUTS ARE CLOSED TO THE PUBLIC! NO FAMILY OR FRIENDS ALLOWED!
Requirements:
Jumps:
combination (females)
Tumbling:
standing/running backhandsprings, back tucks
Toe touch (males)
standing/running backtucks
All-Girl Stunts:
lib & stretch, full twisting dismount, double twisting dismounts
Coed Stunts:
toss hands lib & stretch, full twisting dismount
Males must at least be strong tumblers and/or stunters.
All girls must wear a sportsbra (not a tank top), cotton shorts or hot pants (bikers), ankle socks, tennis
shoes, hair in ponytail, no jewelry or gum. Guys must wear t-shirt, socks, tennis shoes, be clean cut, no
jewelry or gum. All tattoos must be covered.
Practices:
Practices will consist of skills, learning new material and strength and conditioning
$ Expenses (cheer)
NCA College Cheer Camp @$350 (Dallas, TX July 24-26) Camp attire (not yet known)
Competition: Nationals @ $800
*A $200 deposit will be due May 22nd. Deposit is non-refundable. This will cover camp and attire
deposits. All exact prices will be given out early June. Monies must be paid in full by July 10.*
TRYOUT CHECKLIST
Application
Release
Information Sheet
Medical History Form
Student Athlete Emergency Contact
Physical Examination
Copy of Insurance Card (front & back)
Recommendation Letter (current coach)
$15 application fee
2- 4x6 photos (face & full body)
Tryout Timeline (Interviews-convocation center/other-Rec Center–Mac Gym)
April 25th 9am-12pm Interviews
May 1st
4:30-6pm Cheer
1:30-3pm Cheer
6pm-9pm Dance
nd
3-4:30pm Dance
May 2
9am-12pm Interviews
April 26th 9am-12pm Cheer
1pm-4pm Cheer
1pm-5pm Dance
5pm-7pm Dance
THE UNIVERSITY OF TEXAS AT SAN ANTONIO
Spirit Program Application
SELECT ONE:
________CHAPARELLE DANCELINE
____April 25-26
__________CHEERLEADER
____May 1-2
Name:________________________________________________ ID #___________________
(Last)
(First)
(Banner ID or SS#)
(MI)
Address:_____________________________________________________________________
(Street)
(City)
(State)
(Zip)
Phone #s: Hm. ______________ WK. _________________ Cell __________________
E-Mail Address:________________________________________________________________
Parent/Guardian: ______________________________ HM Phone #: ______________________
Parent/Guardian Address:________________________________________________________
(Street)
(City)
(State)
(Zip)
Emergency Name & Phone #s: _____________________________________________________
CLASSIFICATION INFORMATION (Check One)
_____Entering Freshman/Name of High School ________________________________________
_____Transfer Student/Name of College or University__________________________________
_____Returning Student: FRESHMAN___
SOPHOMORE ___
JUNIOR ___ SENIOR___
GRADE POINT AVG.: High School average or ranking if entering freshman __________________
Cumulative GPA if transfer or returning student____________________
Will you be working during the year? ______ How many hours ______ On/off campus? _______
BIRTHDATE_________________
(month/day/year)
HEIGHT_______
WEIGHT_________
Male:_____ Female:_____
Any special medical problems?
Yes___
No___
If yes, please explain
____________________________________________________________________________
____________________________________________________________________________
Allergic to any drugs? Yes___
No___
If yes, please explain in detail._____________________________________________________
____________________________________________________________________________
UTSA Spirit Information Sheet
1) Where have you cheered/danced?
2) Which camps have you attended? Where?
3) Cheer: List all standing and running tumbling. Dance: List all technical skills/tricks.
4) Are you a base or flyer? Most difficult stunts you perform (coed or all-girl)?
5) Why have you chosen UTSA as your college education?
6) Why do you want to be a UTSA Cheerleader or Chaparelle Danceline member?
Please prioritize the following from 1-5 (1 being the most important):
___ Academics
___ National Competition
___ Supporting Athletics
___ Extra curricular activities (sororities, fraternities, clubs, etc.)
___ Being a University Ambassador
SPIRIT PROGRAM RELEASE
Name:____________________________________________________________
(Last)
(First)
(MI)
I understand that there are risks associated with the Spirit Program and that as a participant at UTSA, I may
at any time receive an injury while participating in the cheerleader/dancer/mascot activities. My participation
is a privilege and not a right.
By signing this application, I hereby authorize release of information pertaining to my grades and academic
standing at UTSA to the Selection Committee, the coach, and the Spirit Program advisor in order that they
may ascertain my eligibility to tryout and, if selected, to participate as a cheerleader/dancer/mascot. Further,
in signing this application, I agree to provide medical/hospitalization insurance on myself, or should I not be
covered by any policy of my own or my parents/guardian, I agree to be responsible for any medical expenses
incurred as a result of the tryouts. I understand that if I am selected for the Spirit Program, I must provide
proof of medical/hospitalization insurance. If I do not have a policy on myself, individually or through my
parents/guardian, I agree to obtain medical/hospitalization insurance at my expense. I understand that my
personal insurance is the primary coverage and will pay first in case of injury. If I am injured during official
practice at which a designated sponsor is present or during a scheduled performance, the Athletic Department
will provide insurance for injury incurred with the following stipulations: (1) that my personal insurance is the
primary coverage and will pay first in case of injury; the Athletic Department insurance is secondary coverage
and is an “excess policy” (2) that there is a $250 deductible on the Athletic Department policy and (3) that
the Athletic Department insurance policy is not for general medical/hospitalization; it can only cover those
injuries directly related to official cheerleader/danceline/mascot practices or scheduled performances. An
injury sustained by me while practicing or participating in authorized events will be reported to the sponsor
before leaving the area where the injury occurred. The athletic trainer(s) will provide first aid treatments for
injuries only, and only when they (the trainers) are available and if I receive such treatment, I agree to hold
the involved persons and, or UTSA free from any potential legal claims.
I also understand that some uniforms and equipment are provided to the cheerleader/dancer/mascot;
however, I understand that members of the Spirit Program may incur other expenses. If I am selected to the
team I will have to pay any and all deposits for camp and attire. Should I give up my right to the team all
monies paid will be non-refundable.
I have read and I understand the RELEASE statement above.
__________________________________
(signature)
___________________________
(date)
__________________________________
(name of insurance)
___________________________
(policy #)
_________________________________________________________________
(name and phone number in case of emergency)
If under 18 years of age—parents/guardian must also sign.
___________________________________
(signature)
___________________________
(relationship)
THE UNIVERSITY OF TEXAS – SAN ANTONIO
Athletic Training Department
Health Insurance Form
2009-2010
(Please type or print legibly and include front and back copy of insurance card)
Please check the appropriate box:
 My son/daughter does have current health insurance.
 My son/daughter does not have current health insurance.
STUDENT-ATHLETE INFORMATION
Name:
Sport:
Social Security #: ______________________________
Date of Birth:
Banner ID: _________________________
MM/DD/YYYY
Email: ____________________________
INSURANCE INFORMATION
Insurance Company:
Telephone: (___)___________________
Claims Mailing Address:
City:
State:
Zip:
Name of Policy Holder:
Social Security #: _________________________
Policy Holders Date of Birth:________________________
Policy or ID #:
Group #:
Effective Date: From
to
Deductible: $______________
MM/DD/YYYY
MM/DD/YYYY
Please check the appropriate box.
This policy is a: ____PPO_____POS_____HMO_____Other:_______________________________
Are there any restrictions to this insurance policy?
 NO
 YES - If you answer yes, please explain:
______________________________________________________________________________________
______________________________________________________________________________________
Is the above student-athlete covered under a Dental Policy? ____Yes ____No
If you answered yes, please include a front and back copy of the dental insurance card if it is different from your health
insurance card.
Is the above student-athlete covered under an eye care policy? ____Yes____No
If you answered yes, please include a front and back copy of the eye card card.
Is the above student-athlete covered under a drug prescription plan? ____Yes____No
If you answered yes, please include a front and back copy of the prescription card if it is different from your health
insurance card.
I certify that the above insurance information to my knowledge is accurate and up-to-date. Should there be any changes
in regards to the status of my health insurance I will notify the UTSA athletic training department immediately.
____________________________________
Signature of Policy Holder
_____________________________
Date
UTSA Athletic Training Department
Student Athlete Emergency Contact Form
2009-2010
(Please type or print legibly and complete all requested information)
STUDENT-ATHLETE INFORMATION:
Name:
Sport:
Date of Birth:
Social Security#: __________________________
MM/DD/YYYY
Banner number: _@____________________
Email Address:______________________________
Local Address:
Student-Athletes Local Phone: (____)_______________________________
City:
State:
Zip:
Name of Parent/Guardian: _____________________________________________
Permanent Address:
City:
State:
Zip:
Parents/Guardian Phone: (____)________________________________
EMERGENCY CONTACT INFORMATION:
Primary Contact Name:
Relationship: __________________________
Address:
City: ______________________________
State: ______________ Zip:
Home Phone: (____)________________________ Cell Phone: (____)____________________________
Work Phone: (____)________________________ Email: ____________________________:
**For your secondary emergency contact, please list someone other than a coach,
teammate, or parent/guardian.
Secondary Contact Name: _____________________________ Relationship: ________________________
Address:
City: _________________________________
State:
Zip:
Home Phone:(____)______________________ Cell Phone: (____)__________________________
Work Phone: (____)_____________________________
PREPARTICIPATION PHYSICAL EVALUATION
ATHLETICS
2009-2010
Please note – ALL student-athletes MUST have taken and passed a yearly physical examination prior
to participation in intercollegiate athletics at UTSA. This applies to all scholarship, non-scholarship
student-athletes including those who wish to try out for any intercollegiate team. This also includes
members of the cheerleading and dance line. This MUST be signed by a licensed physician only. UTSA
reserves the right to require anyone who has had a physical examination by his or her physician to be
examined by a UTSA physician prior to participation in intercollegiate athletics.
LAST NAME______________________________FIRST NAME_______________________
Date of Birth:___________________
Sex: Male/Female
Banner Number: @_______________Social Security #:___________________
Sport(s) (include position/event)
Volleyball
Men’s Basketball
Men’s Track/Field – Cross Country
Men’s Tennis
Baseball
Men’s Golf
Cheerleading
Soccer
Women’s Basketball
Women’s Track/Field – Cross Country
Women’s Tennis
Softball
Women’s Golf
Dance Line
MEDICAL HISTORY
Explain “Yes” answers below
Circle questions you don’t know the answers to
YES NO
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
YES NO
Has a doctor ever denied or restricted your
participation in sports for any reason?

Do you have an ongoing medical condition
(like diabetes or asthma)?

Are you currently taking any prescription or
nonprescription (over-the-counter) medicines
or pills?

Do you have allergies to medicines, pollens,
foods, or stinging insects?

Have you ever passed out or nearly passed out
DURING exercise?

Have you ever passed out or nearly passed out
AFTER exercise?

Have you ever had discomfort, pain, or pressure
in your chest during exercise?

Does your heart race or skip beats during exercise? 
Has a doctor ever told you that you have:
(Check all that apply)
 High blood pressure
 A heart murmur
 High cholesterol
 A heart infection
Has a doctor ever ordered a test for your heart?
(For example: EKG, echocardiogram)

Has anyone in your family died for no apparent
reason?

Does anyone in your family have a heart problem? 
Has any family member or relative died of heart
problems or of sudden death before age 50?

Does anyone in your family have Marfan
syndrome?

Have you ever spent the night in a hospital?

Have you ever had surgery?

Has a doctor ever told you that you have asthma
or allergies?

Do you cough, wheeze, or have difficulty breathing
during exercise?

Is there anyone in your family who has asthma?

Have you ever used an inhaler or taken asthma
medicine?

Were you born without or are you missing a kidney,



















an eye, a testicle, or any other organ?

22. Have you had infectious mononucleosis(mono)
within the last month?

23. Do you have any rashes, pressure sores, or other
skin problems?

24. Have you had a herpes skin infection?

25. Have you ever had a head injury or concussion?

26. Have you been hit in the head and been confused
or lost your memory?
27. Have you ever had a seizure?

28. Do you have headaches with exercise?

29. Have you ever had numbness, tingling, or weakness
in your arms or legs after being hit or falling?

30. Have you ever been unable to move your arms or
legs after being hit or falling?

31. When exercising in the heat, do you have severe
muscle cramps or become ill?

32. Has a doctor told you that you or someone in your
family has sickle cell trait or sickle cell disease?

33. Have you had any problems with your eyes or
vision?

34. Do you wear glasses or contact lenses?

35. Do you wear protective eyewear, such as goggles
or a face shield?

36. Are you happy with your weight?

37. Are you trying to gain or lose weight?

38. Has anyone recommended you change your weight
or eating habits?

39. Do you limit or carefully control what you eat?

40. Do you have any concerns that you would like
to discuss with a doctor?

FEMALES ONLY
41. Have you ever had a menstrual period?

42. How old were you when you had your first
menstrual period?

43. Do you experience heavy bleeding and/or cramping
during your periods?

44. How many periods have you had in the last 12
months? ____________
Explain “Yes” answers here:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
______
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
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Student Athlete’s Initials ______
ORTHOPEDIC HISTORY
Explain “Yes” Answers
YES
NO
1. Have you ever had a neck injury that disabled you for a week or longer?
Type of injury ________________________________Dates ___________


2.
Have you had a broken bone or fracture in the past 2 years?
Type of injury ________________________________Dates ___________


3.
Have you had a shoulder injury in the past 2 years that disabled you for
week or longer (dislocation, separation, etc.)?
Type of in injury ______________________________Dates ___________


4.
Have you ever had shoulder surgery?
What was done? _______________________________Dates ___________


5.
Have you ever injured your back?
Type of injury ________________________________Dates ___________


6.
Do you have back pain? (Check those that apply)




Seldom
With Vigorous Exercise
Occasionally
With Heavy Lifting
Frequently
7.
Have you injured your knee in the past 2 years? If yes, Right
or Left
What was done? ____________________________________Date __________
8.
Have you been told by a doctor or athletic trainer that you injured the
cartilage in your knee? If yes, Right
or Left
Dates _________


Have you been told by a doctor or athletic trainer that you injured the
ligaments in your knee? If yes, Right
or Left
Dates _________


10. Have you ever had knee surgery? If yes, Right
or Left
What was done? ____________________________________Date __________


11. Have you had a severe ankle sprain in the past 2 years?
If yes, Right
or Left
What was done? ______________Date __________


12. Do you have a pin, screw, plate, rod or other hardware in your body?
If yes, Where in your body? __________________________Date __________


13. Do you regularly use a brace or other assistive protective device?
If yes, Where on your body? __________________________Date __________


9.
SOCIAL HISTORY
YES
NO
1.
Do you feel stressed out or under a lot of pressure?


2.
Are you currently taking any supplements to help you gain or lose weight or improve your performance?
Please list __________________________________________________________________________


I herby state that, to the best of my knowledge, my answers to the above questions are complete and correct.
Signature of Student-Athlete: ___________________________________________ Date: _______________
Name:_________________
Sport:_____________________
PHYSICAL EXAMINATION
2009-2010
VITAL SIGNS
Height _____________Weight ____________BMI _____Pulse _____BP___/____ (___/____, ___/___)
Vision R20 /___ L20 / ___ Corrected: Y or N / Pupils: Equal _____Unequal _____
To Be Completed By Medical Personnel:
Normal
MEDICAL
Appearance
Eyes/ears/nose/throat
Hearing
Lymph nodes
Heart
Murmurs
Pulses
Lungs
Abdomen
Genitourinary (males
only)
Skin
MUSCULOSKELETAL
Neck
Back
Shoulder/arm
Elbow/forearm
Wrist/hand/fingers
Hip/thigh
Knee
Leg/ankle
Foot/toes
*Multiple-examiner set-up only.
Findings
Initials*
Notes from above physician examination: ___________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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Special Tests Ordered: ________________________________________________
__________________________________________________________________
__________________________________________________________________
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To Be Completed By Medical Personnel:
Physician Clearance
I certify that I have examined this student on this date and that, based on the
examination required by UTSA and the student’s medical history as furnished to
me, this student is cleared to participate with:
No restrictions
The following restrictions (Explain below)
Not cleared to participate:
Deferred – may be reconsidered after further evaluation (Explain below)
Not fit (Give reason below)
Explanation_________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
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Examiner’s Signature:
_____________________________________________Date: ________________
Physician Please Print Name:___________________________________________
Address:___________________________________________________________
City: ____________________________ State:_____ Zip Code: _______________
Telephone Number: __________________________