NCAA Division III Athletics
Intercollegiate athletics participation forms
The forms located below are intercollegiate athletic participation forms required for athletics
participation during the 2007-2008 academic year.
In order to participate in intercollegiate athletics at Medaille College all student-athletes must
have a pre-participation physical each year. It is recommended that student-athletes see their
own doctor for these physicals. For those student-athletes who are not able to see their own
doctor, physicals will be conducted at Medaille College for $15. If you would like to schedule
an appointment with the doctor through Medaille you must call Laura at 716-880-2130 to
schedule an appointment. The date and time of the physicals will be determined in early August.
Prior to any athletics participation, the following information must be on file with the athletic
department: proof of a recent physical exam (valid for one year from the date of completion),
proof of medical insurance, completed participation form and a copy of the student-athlete’s
insurance card. Please download all of these forms and return the Athletic Physical form,
Insurance information form, Participation form as well as a copy of your insurance card.
Fall sport athletes (men’s soccer, women’s soccer, women’s volleyball, men’s and women’s
cross country and golf) should return forms prior to August 15, 2007. All other sports
should return the forms prior to September 5, 2007. Complete all sections of the forms,
incomplete sections may result in delayed participation in intercollegiate athletics. Upon
completing these forms, please mail completed forms to:
Associate Athletic Director
18 Agassiz Circle
Buffalo, NY 14214
Please contact me with any questions you may have.
Medaille College Athletic Physical
THIS FORM MUST BE COMPLETED PRIOR TO PARTICIPATION IN INTERCOLLEGIATE ATHLETICS
Athlete’s Name: School ID#:
Sports: _________________________________ Year in school: FR SO JR SR 5th
Athlete’s Campus Address: _____________________________________Campus/Cell Phone: ______________
Athlete’s Home Address: City:
State: Zip Code: Athlete’s Home Phone Number: _______________________________
Date of Birth: Age: M F
Vision: Glasses or Contacts:
Hearing: Hearing Aid:
Any episodes of passing out during or after exercise?
If yes, have you seen a physician, and what was the diagnosis?
Asthma: Y N Concussion or loss of consciousness: Y N
Diabetes: Y N High Blood Pressure: Y N
Allergies: Y N Fainting or dizziness with exertion: Y N
Allergies: Y N
Allergy and reaction: _________________
Physical limitations: Y N
Medications taken on a regular basis:
Name of medication: Dosage:
General: Normal: Abnormal:
(Any heart condition must be noted plus any necessary medication.)
Orthopedic: Normal: Abnormal:
Hamstring Flexibility: Good: Fair: Poor:
__________ There are no restrictions for participation in intercollegiate athletics.
All tests are within normal limits.
__________This student may participate only after the following steps have been taken to ensure good health.
Physician’s signature: __________________________________________ Date: _____________________
Physician’s name: ___________________________________Address: _____________________________
(printed or stamp)