ࡱ> @B? #bjbjAA 0>#y#y`````ttttD,t+------,^Y`Y``n.``++s} .0NN`|YYN &:    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. Signature_______________________________________ Date________________________________ 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. Signature______________________________________ Date________________________________________ 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. 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