Physician Release Form Please have your physician fill out all the fields below and submit. Please enable JavaScript in your browser to complete this form.Student's Name: *FirstLastDate of Birth: *Diagnosis: *The above named individual is a patient of mine and/or after a thorough and complete examination, I recommend the following regarding participation in recreational classes at Whole Children / Milestones Rec, including martial arts, dance, gymnastics, yoga, and other movement including jumping, rolling, hanging, swinging, and turning up-side-down.Full and unrestricted participation. Participation with the following restrictions and/or precautions: No participation due to:Physician Name: *FirstLastPractice Name: *Street Address: *City, State, Zip: *Phone: *Signature: *Today's Date:Submit
