Athletics Information Form

Athletics Information Form

*required fields

*First Name

*Last Name

*Current Grade Level

*Date of Birth

*Age

English Name or Nickname

*Insurance Provider

If Other, please enter name

*Policy or Card #

*In Emergency Notify

*Relationship to Student

*Emergency Contact Email

*Emergency Home/Cell Phone #

Family Doctor

Doctor City

*List any current medications you are now taking, including vitamins, supplements and prescription drugs.

*List any allergies you have (drugs, tape, insects, plants, foods) and describe what happens (reaction).

Please check the box if you can answer “YES.” Have you ever injured your...

Head

Neck

Shoulder

Clavicle

Arm

Elbow

Wrist

Hand

Fingers

Abdomen

Ribs

Back

Hips

Groin

Thigh

Hamstring

Knees

Legs

Ankle

Foot

Toes

None

If you answered “YES” to any of the above:

Have you ever had Orthopedic Surgery?

Have you ever had a surgery for a bone or joint repair? Do you still have any pins, plates or screws?

Have you been medically advised to have surgery?

*Have you ever had a Concussion (Head Injury)?

Yes

No

*If yes, please explain any occurrences including: Date of Injury, Cause, Treatment, time off, etc.

Check any medical symptoms that you are currently experiencing or have experienced in the last 5 years:

Chest Pain

Respiratory Complications

Cardiovascular Complications

Hematological Complications

Lymphatic Complications

Neurological Complications

Psychiatric Complications

Gastrointestinal Complications

Weight Gain

Weight Loss

Musculoskeletal Complications

Hepatitis

Shortness of Breath

Irregular Heart Beat

Heart Disease

Heart Murmur

Kidney Problems

Stomach Ulcer

Asthma

Jaundice

Epilepsy

Mononucleosis

Gout

Appendicitis

Hernia

Back Pain

Headaches

Hives, Rash or Skin Infections

Concussions

Mental or Nervous Disorder

Blurred or Double Vision

Loss of Consciousness

Nose Bleeds

Cyst, Tumor, Growth

Dizziness

Intestinal Disorder

Other

If Other, please explain

Have you ever experienced any tingling or numbness?

Yes

No

Have you ever had a fainting episode?

Yes

No

Have you ever suffered from heat exhaustion or stroke?

Yes

No

Have you ever had excessive urination or thirst?

Yes

No

Has any member of your family immediate or distant, collapsed suddenly during sport participation?

Yes

No

Check the conditions that apply to you or to any member of your family:

Asthma

Cancer

Cardiac Disease

Diabetes

Hypertension

Epilepsy

Allergies

Tuberculosis

Heart Disease

Mental Illness

Blood Disorder

Neurological Disorder

High Blood Pressure

Sickle Cell Anemia

Please check the box if you can answer “YES.” Do you:

Wear Glasses

Wear Contacts

Wear Glasses during sports

Wear Contacts during sports

Suffer from any other eye trouble

Wear a mouth guard for sports

Have any false teeth

Have braces or dental supports

Suffer from any other dental problem

If Other, please explain

Please check the box if you can answer “YES.” Do you use:

Cigarettes

Drugs (over the counter or otherwise)

Alcohol

Caffeine (coffee, shots, Red Bull, pills, etc.)

Performance Enhancing Supplements

Pre or Post Workout Supplements

None

*Student's Full Name: By entering my full name in this field, I attest that the information provided is current, truthful, and accurate to the best of my knowledge.

*Parental Communication: By entering my full name in this field, I attest that I have discussed this form with my parents and have confirmed with them the information provided is current, truthful, and accurate.

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2619 Niagara Parkway
Fort Erie, Ontario, L2A 5M4
Phone: (905) 871-6980

About Us

Niagara Christian Collegiate (NCC) is an independent, non-denominational Christian school located on the beautiful Niagara River near Niagara Falls, Ontario, Canada.

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