Athlete Enrollment/medical Release Form
ADVERTISEMENT
1
2Athlete Enrollment/Medical Release Form
(This form must be completely fi lled out or it will be returned.)
□ Renewal
□ New
□ Updated
Check one:
Submission Date: ________________________
A: Athlete’ s Name: ________________________________________________________________________
Home Phone: (______) ____________________________ Sex:_______ Age:_______ Date of Birth: ______ / ______ / _________________
Street Address: _______________________________________________________________________________________________________
City:
_________________________________________________________
State:
___________
ZIP:
______________________
Solely to help us comply with government record keeping, reporting and other legal requirements, please check
what applies:
□ White
□ Black
□ Hispanic
□ American Indian/Alaskan Native
□ Asian Pacific Islander
□ Other __________________________
B: Head of Delegation: ______________________________________
Delegation Code: ______________________________________
Cell Phone: (______) ________________________________________
E-mail: ________________________________________________
Street Address: ______________________________________________________________________________________________________
City: ______________________________________________________
State: ______________ ZIP: ______________________________
C: Parent/Guardian Name: ___________________________________
E-mail: ________________________________________________
Home Phone: (____) ________________________________________
Cell Phone: (________) __________________________________
Street Address: _______________________________________________________________________________________________________
City: ______________________________
State: __________________
ZIP:
__________________
D: Person to Notify in Case of an Emergency □ (Check if it is the same as above.)
Name: ____________________________________________________
Relationship to Athlete: ________________________________
Home Phone: (____) ________________________________________
Cell Phone: (________) __________________________________
Street Address: ______________________________________________________________________________________________________
City: ______________________________________________________
State: ______________ ZIP: ______________________________
E: Name of Person Completing this Form: _______________________________________________________________________________
Physical Examination
Normal/Abnormal
Normal/Abnormal
Normal/Abnormal
□
□ Vision
□
□ Cardiovascular system
□
□ Cranial nerves
Athlete’ s height: _________
□
□ Hearing
□
□ Respiratory system
□
□ Coordination
Weight: _________
□
□ Oral cavity
□
□ Gastrointestinal system
□
□ Reflexes
Blood pressure: ____/______
□
□ Neck
□
□ Genitourinary system
□
□ Extremities
□
□ Skin
□ Yes
□ No
□ New Problem
1. Heart disease/heart defect/high blood pressure
Please Note
□ Yes
□ No
□ New Problem
2. Chest pain or fainting spells
* An up-to-date health history and a physical
□ Yes
□ No
□ New Problem
examination performed by a licensed
3. Seizures/Epilepsy
physician is required upon entry into the
□ Yes
□ No
□ New Problem
4. Diabetes
program.
□ Yes
□ No
□ New Problem
5. Concussion or serious head injury
* A physical examination is required every 3
□ Yes
□ No
□ New Problem
6. Major surgery or serious illness
years for items 1- 4, 22
□ Yes
□ No
□ New Problem
7. Heat exhaustion/stroke
* A physical examination is required for all
□ Yes
□ No
□ New Problem
8. Visually impaired/contact lenses/glasses
athletes with a “new problem” response to
□ Yes
□ No
□ New Problem
9. Blindness/major visual problem
items 6 - 10.
□ Yes
□ No
□ New Problem
* Athletes must submit a Medical Release
10. Hearing impaired/hearing aid/hearing loss
Form every 3 years whether or not an
□ Yes
□ No
□ New Problem
11. Deaf/complete hearing loss
examination is needed.
□ Yes
□ No
□ New Problem
12. Serious bone or joint disorder
13. Allergic to the following:
Current Prescription Medication
Medicines: ________________________________________________________________
* First Medication: ________________
Foods: ___________________________________________________________________
Amount: ______________________
Insect sting/bite: ___________________________________________________________
Time: _________________________
14. Special diet: ________________________________________________________________
Date Prescribed: ____/_____/_____
□ Yes
□ No
□ New Problem
15. Asthma
□ Yes
□ No
16. Tobacco use
□ Yes
□ No
□ New Problem
17. Tendency to bleed easily
* Second Medication: _____________
□ Yes
□ No
□ New Problem
18. Emotional problems/psychiatric disorder
Amount: ______________________
□ Yes
□ No
□ New Problem
19. Sickle Cell trait or disease
Time: _________________________
□ Yes
□ No
□ New Problem
20. Immunizations are up to date
Date Prescribed: ____/_____/_____
21. Date of last tetanus: _____/_____/_________
□ Yes
□ No
22. Down syndrome
* Third Medication:_______________
□ Yes
□ No
Have cervical spine (neck/bone) xrays been done?
□ Yes
□ No
Atlantoaxial Instability
Amount: ______________________
Time: _________________________
Please check any of the following that apply:
□ Non Verbal
□ Walker
□ Crutches
□ Wheelchair
□ Hepatitis
□ Shunts
Date Prescribed: ____/_____/_____
B-7
2014 SOTX INFORMATION GUIDE
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal