Pre Season Form

Email address *

First name *

Last name *

Address 1 *

Address 2

City *

State *

ZIP Code *

Cell Phone Number

Sport(s) *

DOB *

Gender

Primary Care Physician *

Primary Care Physician Contact Number *

Emergency Contact Name (1) *

Emergency Contact Relationship (1) *

Emergency Contact Phone (1) *

Emergency Contact Address (1) *

Emergency Contact Name (2) *

Emergency Contact Relationship (2) *

Emergency Contact Phone (2) *

Emergency Contact Address (2) *

Medical Insurance Carrier *

Policy No. *

Address *

Phone *

Subscriber's Name *

Relationship *

If other please explain

Medications

Allergies

Notes

1. If you will be carrying prescription medication, you are advised to consult with your physician regarding secondary dosage in the event of possible loss or water contamination. 2. If you have ever had a systemic reaction to an insect sting, we recommend you consult your physician about carrying a personal Ana-kit or Epi-Pen. Even with no prior history it is possible for a person, for a variety of reasons, to develop a life-threatening systemic reaction. Because our activities are often far from professional medical care, we advise everyone to consult with their physician regarding a prescription for these kits. Due to New York State regulations, the coaching staff may not legally dispense controlled prescription drugs and will not be carrying group Ana or Epi devices.

Past Injuries/ Surgery/ Joint Problems

Environmental Emergencies (heat and cold conditions)

Frostbite Hypothermia Circulatory problems Heat stroke Raynard's syndrome

Special dietary requirements

Any other injuries or medical conditions?

Swimming Assessment *

Some of the training for Intercollegiate Athletics may involve activities in a water environment, which require basic swimming skills. We ask that participants self-assess their own comfort level in and around the water. We recommend that you do not register for a course involving water activities if you are a non-swimmer. Please rate your swimming ability below:

Non-Swimmer Recreational Swimmer Strong Recreational Swimmer Competitive Swimmer

Agreement to Participate

I am aware that playing or practicing in any sport can be a dangerous activity involving many risks, including injury. I understand that the dangers and risks of playing or practicing in any sport include, but are not limited to: death, serious neck and spinal injuries which may result in complete or partial paralysis or brain damage, serious injury to virtually all bones, joints, ligaments, muscles, tendons, and other aspects of the muscular-skeletal system and serious injury or impairment to other aspects of my body, general health and well being. I specifically acknowledge that contact sports can involve even greater risk of injury than some other sports. Because of the dangers of participating in the above sport, I recognize the importance of following the coach?s instructions regarding playing techniques, training, rules of the sport, and other team rules and obeying such instructions. I understand and endorse the communication among the coach(es), athletic trainer, Paul Smith?s College medical staff, and others with regards to my medical condition and health, as this allows for better treatment and rehabilitation. In consideration of the College permitting me to practice, play, or to try out for the College?s team and to engage in all activities related to the team, including practicing, playing and traveling, I hereby voluntarily assume all risks associated with participation and agree to exonerate and save harmless the College, their agents, servants and employees, the athletic staff of the College, the physicians and other practitioners of the healing arts treating me from any and all liability, claims, causes of action or demands of any kind and nature whatsoever which may arise by or in connection with my participation in any activities related to the College sports team. The terms hereof shall serve as a release and assumption of risk for my heirs, estate, executor, administrator, assignees, and all members of my family. I hereby agree to submit any disputes that may arise between myself and the College, its agents, servants and employees, the athletic staff of the College, the physicians and other practitioners of the healing arts treating me, and their agents, servants and employees, in connection with my activities at the College, to binding arbitration before three arbitrators, in accordance with the Rules of the American Arbitration Association. ???

I agree

Signature *

I have reviewed this entire medical form and verified that all information is given fully and truthfully. To the best of my knowledge, I am capable of safely participating in the sport(s) listed on the front of this form. In the event of an emergency, permission is given for any anesthesia and/or surgery at a medical facility that may become necessary for my immediate well-being. I understand by printing my name below I am submitting my online signature

Parent/ Legal Guardian Signature (if under 18)

I understand by printing my name below I am submitting my online signature

* required field