Bow Police Department______                 ___________________ 
7 Knox Road (Physical)                                                         Margaret M. Lougee
10 Grandview Road (Mailing)                                                   Chief of Police
Bow, New Hampshire 03304				                                      
TEL: (603) 223-3950

BOW POLICE DEPARTMENT
MEDICAL CLEARANCE FORM
(SUBMIT FOR INDIVIDUAL PERSON)

Print Applicant’s Name:_____________________	  Date of Birth: _____________

The above individual is being asked to take part in a fitness assessment program as part of an overall process to become a police officer.  The fitness assessment involves sub maximal measurements of cardio-respiratory fitness (1.5-mile run), muscular endurance and absolute strength of the arms and chest (push-ups), and muscular endurance of the abdomen (sit-ups).  The assessment scores are listed below as determined from the normative data collected by Dr. Kenneth Cooper of the Cooper Aerobic Institute of Dallas, Texas.

By completing this form, you are assuming any responsibility for our assessment program.  If, however, you know of any reason why the participant should not undertake a basic assessment of fitness as listed above, we would be most grateful if you could indicate that below.  Thank you for your cooperation in this matter.

I have examined the above captioned applicant on the following date __________________ and based on my findings:

_______________  I know of no reason why the applicant may not participate.

_______________  I recommend that the applicant NOT PARTICIPATE

Signature of Health Care Provider: ________________________________________

Name and Address of Health Care Provider: ________________________________

____________________________________________________________________

Health Care Provider’s Phone Number: _____________________________________