Wellesley College Athletic Training Walk-On/ Tryout Release

This is a preliminary medical history form for tryouts/ walk-ons. If selected for the team, you will be required to have a PPE (pre- participation exam) with the athletic trainers as soon as possible after your selection. Please note! Effective August 1, 2007, the NCAA passed a bylaw stating that any athlete who tries out for an athletic team must have proof of a recent physical examination by a physician (within six months) before initial participation. If you have not had a physical within six months, you will not be able to try out until you have one and send us the appropriate documentation. If you have not had a physical in the last six months and are an upperclass student, you must contact the Health Center at x2810 to schedule one prior to trying out, or schedule one with your personal physician. If you are an upperclass student and have had a physical in the last six months, you will need to obtain a copy of that physical. If you are a first year student, we can obtain your physical date from the Health Center, so you do not need to contact them. There are no exceptions!

Name: ______D.O.B ______

Class year: ______Sport trying out for: ______

Have you ever tried out for a varsity athletic team at Wellesley College? When? ______

Home address: ______

City: ______State: ______Zip: ______

Home phone: ______Cell/dorm phone: ______

Parent/guardian name: ______

Parent alternate contact number: ______

Health insurance company: ______

Policy number: ______Group number: ______

Policy holder: ______Insurance co. phone: ______

Primary care physician: ______Phone: ______

I understand that athletic participation is not without risks. Risks of athletic participation include but are not limited to significant joint or bone injury, brain or spinal cord injury, internal organ injury and death. I am willing to accept these risks and will not hold Wellesley College responsible for any injuries I sustain while participating in this intercollegiate tryout. Furthermore, I understand that this is not a medical examination, only a basic screening of general health to participate in a tryout.

Signature______Date______

I grant the athletic training staff of Wellesley College permission to secure necessary and appropriate emergency and non-emergency medical care. I also grant permission to Health Services to share all health related information with the athletic trainers as appropriate.

Name: ______Sport: ______Grad year: ______Please answer the following questions honestly. Explain all “YES” answers below. YES NO

1. Have you had a physical examination by a physician within the past six months? ______

If you selected “no” you must provide proof of a physical examination within six months as per NCAA bylaw initiated as of August 1, 2007. No athlete or prospective athlete may try out or participate unless this bylaw is met.

2. Do you have an ongoing or chronic illness (this includes mental illness)? ______

3. Have you ever had surgery? ______

4. Are you currently taking any prescription or over-the-counter medications? If so, please list below. ______

5. Do you have chronic bronchitis/asthma? If yes, do you use an inhaler? ______

6. Do you have any allergies to food, medications, stinging insects, or pollen? ______If yes, do you use an epi-pen for allergic reactions?

7. Have you experienced chest pain, wheezing, coughing, or dizziness during or after exercise? ______

8. Have you ever been told that you have a heart murmur or high blood pressure? ______

9. Has any family member or relative died of heart problems or sudden death before the age of 50? ______

10. Have your ever had a head injury or concussion? Ever been knocked out or suffered memory loss? ______

11. Have you ever had a seizure? ______

12. Have you ever had numbness or tingling in your arms, hands, legs, or feet? ______

13. Have you ever become ill from exercising in the heat? ______

14. Do you wear glasses, contacts, or protective eyewear or dental appliance? ______

15. Have you ever had a sprain, strain, or swelling after injury? ______

16. Have you broken or fractured any bones or dislocated any joints? ______

17. Has a physician ever advised you not to participate in athletics or physical activity? ______

Write the number of the question and explain all YES answers below. Be sure to indicate right/left as appropriate. Include dates of injuries/surgeries if possible.

______

I hereby state that, to the best of my knowledge, my answers to the above questions are complete and accurate.

All athletes are required to show proof of medical insurance before participating in any physical activity. Do not forget to enclose a photocopy of both sides of your current medical insurance card! Families are urged to check with their insurance carriers to be certain that athletically related injuries and illnesses while away from home will be covered. If the policy will not cover a dependent while away, or will not cover medical and dental expenses in full, the college strongly recommends families purchase the college insurance policy as additional coverage. The athletic department does not carry personal health insurance for student-athletes. The purchase of acceptable health insurance is the sole responsibility of the student-athlete and/or her family. For more information on the college’s medical insurance option, go to http://www.wellesley.edu/Health/Information/insurance.html Please be assured that all medical and insurance information received are confidential.