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Preparticipation Physical Evaluation (PPE)

Statement of Verification


I hereby declare and affirm that the information contained in the Eligibility Form has been legitimately provided by a physician or qualified healthcare personnel authorized to conduct the examination.



First Dancer's Name

First Name*

Middle Name

Last Name*
First Dancer's Date of Birth*
First Dancer's Signature*
Second Dancer's Name

First Name*

Middle Name

Last Name*
Second Dancer's Date of Birth*
Third Dancer's Name

First Name*

Middle Name

Last Name*
Third Dancer's Date of Birth*
Fourth Dancer's Name

First Name*

Middle Name

Last Name*
Fourth Dancer's Date of Birth*
Fifth Dancer's Name

First Name*

Middle Name

Last Name*
Fifth Dancer's Date of Birth*
Sixth Dancer's Name

First Name*

Middle Name

Last Name*
Sixth Dancer's Date of Birth*
Seventh Dancer's Name

First Name*

Middle Name

Last Name*
Seventh Dancer's Date of Birth*
Eighth Dancer's Name

First Name*

Middle Name

Last Name*
Eighth Dancer's Date of Birth*
Ninth Dancer's Name

First Name*

Middle Name

Last Name*
Ninth Dancer's Date of Birth*
Tenth Dancer's Name

First Name*

Middle Name

Last Name*
Tenth Dancer's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
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PREPARTICIPATION PHYSICAL EVALUATION (PPE) or Sport Physical
  
PPE- MEDICAL ELIGIBITY The Medical Eligibility Form is the only form that should be submitted to a school or sports organization.
Valid file types: JPG, GIF, PNG, and PDF
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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