Medical Clearance Form The Ymca printable pdf download

Medical Clearance Form

Dear Doctor:

____________________________________________________________ has applied for enrollment in the

YMCA Diabetes Prevention Program. This program involves losing weight through healthy eating and

being more physically active. The exercise programs are designed to start easy and become

progressively more difficult over a period of time. Brisk walking is recommended as the primary

method of increasing physical activity.

By completing the form below, you are not assuming any responsibility for our administration of the

exercise programs. If you know of any medical or other reasons why participation in the YMCA

Diabetes Prevention Program by the applicant would be ill-advised, please indicate so on this form.

If you have any questions about the YMCA Diabetes Prevention Program, please call Cyndi Portteus at

(317) 266-9622.

Report of Physician



I know of no reason why the applicant may not participate.



I believe the applicant can participate, but I urge caution because

_________________________________________________________________________________



The applicant should not engage in the following activities:

_________________________________________________________________________________



I recommend that the applicant NOT participate

Physician signature ____________________________________________ Date ____________

Name (printed) ______________________________________________________________________

Address _________________________________________ Telephone ______________________

City and State __________________________________________ Zip ______________________

Please fax form to:

Diabetes Prevention Program

YMCA of Greater Indianapolis

(317) 266-2845

Medical Clearance Form The Ymca