Columbus State Community College
Athletic Information Form

Name_____________________________________ Date________ Sport_____________________

School Information:                                       Home Information:

Address ___________________________ Address _______________________________________

City, Zip ___________________________ City, Zip ______________________________________

Phone # ___________________________ Phone # _______________________________________

Person to contact in case of emergency_____________________________ Phone #______________ Relationship________________

Insurance Information:

Name of insurance company___________________________________________________________________

Address of insurance company_________________________________________________________________

City, state, zip _____________________________________________________________________________

Insurance company phone #___________________________________________________________________

Insurance policy number______________________________________________________________________

Name of insured___________________________________________________________________________________

Emergency Information:

Drug allergies ___________________________________________________

Current medications_______________________________________________

Do you have a history of head injuries or seizures? Yes   No

If yes, please explain___________________________________________________________________________________

Are you allergic to bee or wasp stings? Yes   No

If yes, please explain___________________________________________________________________________________

Do you have any other medical conditions that emergency medical personnel should be aware of?

If yes, please explain___________________________________________________________________________________

Do you have any family history of unexplained or cardiac caused sudden death under age 50?

If yes, please explain___________________________________________________________________________________

Have you ever had any type of surgery?__________________________________________________________________________________

Do you wear glasses or contact lenses when you play? Yes   No

If yes, which do you wear?____________________________________________________________________________________

I hereby give permission to be treated by the Columbus State team physicians and/or their consulting physicians and athletic trainers for any or all medical treatment or emergencies while a member of a Columbus State athletic team to include practices, games, and travel. When necessary, I grant permission for treatment by emergency medical personnel and hospitalization at an accredited hospital.

I certify that no information regarding my medical history has willfully been omitted, and that to the best of my knowledge, recollection, and belief, the information I have given on this record is an accurate and complete account of my medical history.

Athlete Signature__________________________________________________________________________

Special medical alert_______________________________________________________________________

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