| Cobber Athletic Home | Emergency/Insurance Form |
Concordia College Returning Athlete Update
Please print form, fill out completely and return
to:
Stephanie Brandt - Athletic Trainer
Concordia College
901 South 8th Street
Moorhead, MN 56562
Athlete Information
| Name: | Gender: | |
| Date of Birth: | ||
| Class: | Social Security Number: | |
| Sports Playing: | ||
Current Medical Conditions
| Any series illnesses in the last 12 months: | |
| Current Medications/Supplements: | |
| Known Allergies: | |
|
Please list injuries below that were sustained in the last 12 months: |
|
| Head Injuries: | |
| Neck: | |
| Back Injuries: | |
| Shoulder Injuries: | |
| Humeral/Ulnar/Radial Injuries: | |
| Elbow Injuries | |
| Hand/Wrist/Finger Injuries: | |
| Pelvis/Hip Injuries | |
| Thigh Injuries | |
| Knee Injuries | |
| Lower Leg Injuries | |
| Ankle Injuries | |
| Foot/Toe Injuries | |
| The above statements are true to the best of my knowledge.
This athlete gives consent for the team physician, consulting physician, Concordia Student Health Personnel and/or appropriate member of the sports medicine staff of Concordia College to examine records, or be in consultation concerning examination or treatment of the athlete for the express prupose of evaluating the medical and/or physical fitness for participation in, or continued participation in any athletic program at Concordia College. The athlete/parent also gives permission for acceptable diagnostic, therapeutic and emergency operative procedures to be carried out in the treatment of illness and injury sustained while a member of a Concordia College Athletic Teams. |
|
| Signed Date |