Pop Warner Little Scholars, Inc.
2014 PHYSICAL FITNESS & MEDICAL HISTORY FORM
Special Note: This form must be dated after January 1, 2014 and then submitted to your LOCAL Pop Warner organization.
No other forms are acceptable unless Section II is modified or substituted ONLY to comply with local and/or state laws or because of medical practitioner regulations (i.e. the medical practice insists on its own form). In either case, Section I must still be filled out entirely and attached to any modified/substituted form. Section II must be completed in its entirety
ONLY by a Licensed State Examiner (medical doctor, nurse practitioner, etc.)

Section I: FOR PARENT/GUARDIAN COMPLETION ONLY
Legal Name of Participant (must match birth certificate):
Last _____________________________________First____________________________Middle__________________________
Address:_______________________________________ City:____________________________ State: ______Zip:___________
Telephone No:_____________________________ Date of Birth: ____________________________ Male_____ Female _____
Name of Primary Medical Insurance Company:_______________________________ Policy Number: ______________________
Membership Number:_________________ Name of Primary Insured: _______________________________________________
Does primary insured have Medicaid? Yes

No

Does primary insured have Medicare?

Yes

No

Sport (check one): Cheer _____ Dance_____ Tackle_____ Flag_____

----------------------------------------------------------------------------------------------------------------------------------------------PARTICIPANT MEDICAL HISTORY
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Are there any injuries requiring medical attention?
Are there any past surgeries or scheduled surgeries?
Is there any history of concussions and/or head injuries?
Is the