Verification Of Health Insurance Form


SUNY Cobleskill Department of Sport and Exercise
Student-Athlete Name: ________________________________Sport: _____________________
DOB: _______________ Cell Phone # ____________________ 800# _____________________
Home Address: ________________________________________________________________
Emergency Contact and Phone #: __________________________________________________
SUNY Cobleskill does not provide health / sports injury insurance for student-athletes. I
understand that I will be responsible for all medical expenses incurred with participation
in intercollegiate athletics at SUNY Cobleskill.
By signing this form I hereby certify that I have either:
Check one and initial:
______ A) Purchased the School Health Insurance Policy
______ B) I have Health insurance policy that covers athletic related injuries up to $90,000.
Please provide a copy of your insurance card in the space provided.
Paste or Tape in This Space
Copy of the Front and Back of the Insurance Card
Do not use staples
Name: _________________ Sport___________________ Date of Birth: __________
Do hereby grant authorization to The SUNY Cobleskill’s Sports Medicine Staff to release and /or obtain my injury
reports and/or medical records and participation status for any and all injuries /illnesses incurred as a direct result of
or affecting my participation as a member of an intercollegiate athletic team at SUNY Cobleskill. This
information, as warranted and/or appropriate would be released to one or more of the following:
Athletic Administration, Wellness Center, Appropriate athletic team coach, Team physician Family and/or
specialist physician, Hospitals / clinics / ambulance crew, Insurance providers Professional scouts, Parents.
I understand that in accordance with Federal and State laws, this release does not include permission to transmit
information specifically related to HIV (Human Immunodeficiency Virus) the causative agent of AIDS) status, and
if such information is to be released, additional specific release forms are required. I understand that this consent is
valid for 1 academic year from the date of signing and that I may rescind this consent at any time with written
__________________________ _________________________________
Student Signature
Parent signature if under the age of 18


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