Physical Examination Form For A Competition License
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1
2
3Physical Examina on Form and Applicant’s Medical History Form for the purpose of obtaining a PCA Club Racing
Compe
on License.
The Physical Examina on Form is to be fully completed, signed, dated, and stamped by an examining Medical Doctor
and returned to the applicant.
Dear Doctor,
You are being asked to examine this applicant for the purpose of obtaining a compe
on racing license issued by the
Porsche Club of America (PCA) Club Racing. This form concentrates on the organ system and disease processes that
may jeopardize the applicant or others a ending a compe
on race event.
The func onal requirements of a driver in a compe
on automobile are:
1
Ability to rapidly operate accelera on, braking and steering mechanisms/systems
(mechanical assistance allowed).
2
Vision: distant vision correctable to 20/40 each eye, ability to dis nguish basic colors, and
peripheral vision to 70 degrees in the horizontal median for each eye.
3
Minimal chance of sudden incapacita on from any disease process.
4
Ability for rapid mental ac vity and problem solving.
The environment this applicant may operate in is:
1
Temperature extremes from 0 to 120 degrees external to the vehicle (ho er inside).
2
Smoke, fumes, vapor and dust.
3
Noise and vibra on.
4
Poten al for the presence of fire.
Any place where consults are needed, the consultant must have a significant knowledge of the disease
process and the high speed racing environment. The consultant does not have to be a specialist in the
par cular disease process.
Signed
(examining physician or consultant)
date
Applicants are required to submit a current physical examina on:
Annually (1 year) or Biennially (2 years) as determined by the examining Medical Doctor.
Please check the appropriate op on.
In the event of an injury or significant change in medical condi on, the PCA Club Racing Commi ee may require a
complete medical cer fica on prior to the expira on date of this medical form.
Please fully complete, sign, and date the a ached Physical Examina on Form
Thank you for your input.
Sincerely,
The PCA Club Racing Commi ee
11/14
PCA CLUB RACING
1897 MISSION HILLS LANE
NORTHBROOK, IL 60062
phone: 847.272.7764
fax: 847.272.7785
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