Student Athlete Medical Forms

Dear Student Athlete,

I would like to welcome you to the Herkimer County Community College athletic family. I hope you have a safe and injury free experience. Unfortunately, accidents and injuries do occur in athletics. This sometimes involves bracing, rehabilitation, doctor and emergency room visits. We at HCCC, want to ensure that you will receive the best possible care and in a timely fashion. In order to expedite this process some information must be provided prior to your participation.

Below you will find links to forms that you must print and fill out in entirety and to the best of your knowledge. This information is required by both the NJCAA and HCCC, prior to your participation in athletics. If these forms are not filled out completely you will not be allowed to try out or participate in HCCC athletics. A photocopy (front and back) of your current medical insurance card should be on file prior to your participation. Additionally all athletes are required to purchase a supplemental student accident insurance through the school, for a small fee. The supplemental student accident insurance is a secondary insurance, that helps cover medical costs not covered by your primary insurance in the event of an athletic injury. This is all done to ensure you have a safe and healthy experience here at HCCC.

The medical history form should be completed and singed by the student athlete. Circle “yes” or “no” for each question and please provide dates and details when specified. If you commute from home, write “commute” for the school address. The release/waiver form should be read and signed by the student athlete. If you are under eighteen, this form should be also signed by a parent or guardian. The physical exam form should be filled out by your physician. The exam should be dated after June 15th, and must clearly state that you may participate in intercollegiate athletics with no limitations. If you are currently under the care of a physician, physical therapist, chiropractor, etc. for an injury or illness, please have that health care provider fill out a referral form. A written statement by them is required prior to your participation. A copy of your immunization records are also needed prior to your participation.

All medical information is strictly confidential and will be used as an aid in providing you the best health care possible while you are a student athlete at HCCC. In order to ensure this privacy, your knowledge and written consent will be required prior to release of any personal health information.

Everything must be completed and returned to HCCC by August 1st:

Checklist:

______ Medical History Questionnaire Medical History Questionnaire

______ Statement of Insurance and Waiver/Release Form Statement of Insurance and Waiver/Release Form

______ Health History/Physical Exam/Immunization Form Health History/Physical Exam/Immunization Form

______ Photocopy (front and back) of insurance card

______ Supplemental Accident Insurance Brochure/Enrollment Form      Claim Form

______ Referral Form (if necessary)

Please return completed forms prior to first practice to:
Debra Lynch, Health Office, HCCC, 100 Reservoir Rd., Herkimer NY, 13350