Sports Participation Clearance Letter

Clinic/Organization Name: [Clinic/Organization name]

Address: [Street address, City, State, ZIP]

Phone: [Phone number]

Fax: [Fax number]

Sports Participation Clearance Letter

Date: [Date of letter]

Addressee

To: [School/Organization/Athletic Department/League name]

Attn: [Recipient name/title] (If not specified, enter "Not specified")

Athlete Identification

Athlete Name: [Full name]

Date of Birth: [MM/DD/YYYY]

Evaluation Information

Date of Evaluation: [MM/DD/YYYY]

Evaluating Provider: [Provider name, credentials]

Sport(s): [List specific sports] (If no specific sports mentioned, enter "Not specified")

Release Authorization: [Authorized by parent/guardian / Provided to patient/guardian for delivery to school / Other: [brief description]]

Medical Eligibility Determination

Status: [Medically eligible for all sports without restriction / Medically eligible for all sports without restriction, with recommendations for further evaluation or treatment / Medically eligible for certain sports (see Restrictions below) / Not medically eligible pending further evaluation (see Follow-up Requirements below) / Not medically eligible for any sports]

(Select exactly one status; display only the selected option)

Restrictions

(Include this subsection only if status is "Medically eligible for certain sports")

• [Specific functional limitation, sport exclusion, or contact level restriction]
• [Equipment requirement or environmental precaution]
• [Practice/competition/time limitation]

(Use specific, actionable language such as "No collision sports," "Conditioning and non-contact practice only," or "Heat precautions required." Add or remove bullet points as needed.)

Follow-up Requirements

(Include this subsection only if status is "Medically eligible with recommendations" or "Not medically eligible pending further evaluation")

• Needed evaluation/testing: [Specify tests, consults, or documentation required]
• Who must provide clearance: [Provider/specialty or authority]
• Expected timeline: [Timeframe or due date]
• Interim participation: [Permitted activities during evaluation period / No participation permitted until cleared]

Emergency Information for Athletic Staff

(Include only if relevant emergency information is available and authorized for disclosure; otherwise omit this entire section. Reference separate action plans rather than embedding detailed management instructions.)

Allergies: [Allergen(s) / None known]

Relevant Emergency Medications: [Medication name(s) and purpose, e.g., rescue inhaler, epinephrine, insulin / None]

Emergency Contact: [Name, relationship, phone]

Attestation

I have completed a preparticipation evaluation consistent with current guidelines. Detailed examination findings and medical history are maintained in the medical record. This eligibility determination reflects information available on the evaluation date and may require reevaluation if new symptoms, diagnoses, or events occur.

Signature

Provider Signature: ___________________________

Printed Name and Credentials: [Provider name, degrees, credentials]

Date Signed: [MM/DD/YYYY]

Clinic Contact: [Phone] | [Fax]