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Current Athlete Registration Form
There are errors with your form submission. Please review and submit again
Email address *
First name *
Last name *
Address 1 *
ZIP Code *
Cell Phone Number *
Student # *
Current College Year *
Date of Birth (YYYY/MM/DD) *
Last High School Attended *
Health Card # *
Previous POST SECONDARY (college or university) participation: Name of institutions and number of years you played (ie- Queens, 2 years) *
Warning of Risk & Declaration of Release *
I understand that there are intrinsic risks involved with playing a sport at a competitive level. I also understand that in order to compete, teams must travel by bus or van to other colleges. I assume all risks. In consideration of being allowed to be a Loyalist Varsity Athlete, I hereby, for myself, my heirs, executors, administrators, and all others who might claim on my behalf, waive and release Loyalist College and any of its officers, directors, agents, employees or servants from any and all liability arising from being a Loyalist Varsity Athlete. I, the undersigned, hereby give consent to the staff of Loyalist College Athletic Department to access my marks as part of the Athletic Department academic policy. I agree to maintain a minimum 60% cumulative GPA to remain eligible to participate in Varsity Athletics. I also agree that the Athletics Department may release my name and sports pictures to the media or use them in various promotional publications. Lastly, I agree to return any uniforms, equipment, etc., issued to me, in the condition that I received them. In the event that I lose a uniform, etc., I will reimburse the College the replacement cost. (If you are under the age of 18, you must provide the signature of your parent, guardian or legal representative who will accept responsibility with you and on your behalf for the agreements and understandings set out above.)
Emergency Contact Information
Emergency Contact Phone # *
Relationship to Emergency Contact *
Personal Medical History
Please check any of the following that apply to you: *
Have you had a medical illness or injury since your last sports physical?
Have you been in a motor vehicle accident since your last sports physical?
Have you ever had surgery?
Are you currently taking any prescription or over-the-counter medications or pills or using an inhaler?
Are you currently taking any supplements? If yes, please explain below
Do you have any allergies? If yes ? list all allergies below
Do you carry an Epi-pen?
Have you ever passed out during or after exercise?
Have you ever been dizzy during or after exercise?
Have you ever had chest pain during or after exercise?
Have you ever had racing of your heart or skipped heartbeats?
Have you had high blood pressure or high cholesterol
Do you have any circulatory problems?
Have you ever been told you have a heart murmur?
Do you cough, wheeze, or have trouble breathing during or after activity?
Do have asthma?
Do you use an inhaler?
Have you had problems with your eyes or vision?
Do you wear glasses, contacts, or protective eyewear?
Do have any hearing deficits?
Are you susceptible to ear infections?
Do have any skin sensitivities (itching, rashes, acne, warts, fungus, or blisters)?
Have you ever been treated for MRSA or other staph infection?
Have you ever had a seizure?
Do you have frequent or severe headaches?
Do you have headaches brought on by exercise?
Have you ever had a neck injury?
Have you ever had numbness or tingling in your arms, hands, legs or feet?
Have you ever had a stinger, burner, or pinched nerve?
Do you use any additional protective or corrective equipment?
Has a physician ever denied or restricted your participation in sports for any reason?
None of the above apply to me
Please provide any details on any boxes checked above. *
Please select any of the following medical conditions that are in your family: *
High blood pressure
Died suddenly before the age of 50
Sickle cell trait
None of the above apply
Have you ever had a concussion? *
If yes, how many and when did they occur?
Has a physician cleared you to play since your last concussion?
Have you ever had any of the following? *
Cancer (previous or current)
Sickle cell trait
Frequent anxiety or depression
Dental problems, implants, bridges or surgeries (exp wisdom teeth)?
None of the above apply to me
Have you had any problems with any of the following? *
Please provide any details for any of the injuries indicated above:
If you have anything else you wish to disclose, please include it here
* required field