McComb Local School
328 South Todd Street · McComb, OH 45858 · 419-293-3979
Mr. Tony Fenstermaker , Superintendent  · Mrs. Linda Clymer, Treasurer

Physician's Medical Clearance Form

Name:	, has requested use of the
McComb Local School's Fitness Center. A video detailing the equipment and its appropriate use is available and required viewing for all joining the center, and for any physician who wishes to see it. It can be found at www.mccombsc hool.org. The school's fitness room is supervised by volunteers. If you know of any medical reason why participation by the applicant would be unwise, please indicate so on this form. If you have any further question about the facility, the equipment or activities, please call the school at 419-293-3979 .

Physician's Report

I,	(physician's name), give my consent for
 	_ (member's name) to use the McComb Local School's Fitness Center and participate in exercise activities.

Specific  Recommendations:

Restrictions:

Physician's Signature:

Physician's Printed Name:

Physician's Address :

Physician's Phone Number: _		Date:	_

Mr. Jeremy Herr MS/HS Principal (7-12)
419-293-3853
419-293-3107 fax

Dr. Joyce Jackson Elementary Principal (PreK-6)
419-293-3286
419-293-2412  fax