Student Trooper Program
Health Statement - Page 1
Health Statement
Student Troopers Name (Print): ___________________________________________________
Date of Birth:________________________
A qualified medical care physician must complete this section.
Please list below or on an attached page any condition(s) that the Academy Health Unit/Staff should
be aware of regarding the student’s medical history or current condition. Include diabetes,
infections, allergies, inhalers, Epipen, or recent illness or injury that could affect participation in
moderate physical exercise.
Please list any medication(s) the above named student may be taking and the reason for taking the
medication.
I certify that the above named student trooper candidate is in good physical/mental health and
capable of participating in the student trooper program. I certify that his/her medical immunizations
are up to date as prescribed by Massachusetts law.
______________________________________
PHYSICIANS NAME (PRINT)
______________________________________
PHYSICIAN SIGNATURE
______________________________________
ADDRESS
______________________________________
TELEPHONE
______________________________________
DATE
TWO SIDED FORM – SEE REVERSE SIDE
PARENT SIGNATURE REQUIRED ON REVERSE SIDE
