MEDICAL CLEARANCE FORM

TRAINEE’S INFORMATION

_____________________________ _____________________________ __________

LAST NAME FIRST NAME MI

_____/_____/____
DATE OF BIRTH

MEDICAL CLEARANCE TO BE SIGNED BY THE MEDICAL TECHNICIAN

I hereby attest the above-named individual to be in good health with no observed pre-existing
conditions or abnormalities that would prevent his/her to continue with the on-the-job training.

_________________________
Signature
Date:____________