Special Note: This form is to be dated after January 1, 2021 and then submitted to your LOCAL Pop Warner organization. No other forms are acceptable. Section II must be completed in its entirety ONLY by a Licensed State Examiner (medical doctor, nurse practitioner, etc Section II is modified or substituted ONLY to comply with local and/or state laws or 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 I: FOR PARENT/GUARDIAN COMPLETION ONLY
Legal Name of Participant (must match birth certificate):