Physical Examination Form for Athletics
Name:_________________________________
Date:__________________________
Banner ID#:_____________________________
DOB:__________________________
To the Student Athlete: All students who wish to participate in athletic activities sponsored by Gateway
Community College are required to have the following form on file in the College Life Office. Athletic activities shall
include participating in any varsity sport, club sport, and/or intramural programs. The College, endorsing policies
set forth by the NJCAA, requires this form to determine a student’s physical status for participation in sports.
Failure to submit this form will prevent participation in any athletic activities sponsored by the college.
SPORT(S) TO BE PLAYED:
Varisty Sports: These sports are officially sponsored by the College and have direct coaching supervision
and minimal medical care.
____ Basketball (M)
____ Basketball (W)
Club/Intramural Sports: Sponsored by the College with minimal coaching and no minimal medical care.
____ Volleyball
____ Soccer
ATHLETIC ASSESSMENT: Based on your physical examination and the person’s medical, surgical, and family history,
do you feel that this individual is physically capable of participation in the sport(s) he/she has indicated?
____ Yes
____ No
Please Explain:_________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Date of Examination:______________________________________
Physicians’ Signature:______________________________________
Date:__________________________
Physician’s Name:________________________________________
Address:___________________________________________________________________________________
Telephone:_____________________________________________
Sport:____________________________________________________
Date:_______________________
Name:________________________________________________________________________________________
Last
First
MI
DOB:_____________________________
Height:____________________
Weight______________________
Parent/Guardian Information
Name:_________________________________________________________________
Address:_______________________________________________________________
Phone#:________________________________________________________________
Medical Information and History
Physician’s Name:__________________________________________________________
Medical Coverage:__________________________________________________________
Health Status: Excellent________ Good_________ Fair__________ Poor__________
Health Problems at this Time? ____No _____ Yes If Yes, please explain:_________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
List all accidents, injuries, operations, and illness in the past year. Please describe treatment.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Has student ever had treatment for a bone, joint, or muscle disorder? Yes____ No____
If yes, please explain:_____________________________________________________________________
Does the student take medication on a regular basis? Yes______
No______
Reason:________________________________________________________________________________
Does the student suffer from any of the following:
Yes
No
Rheumatic Fever
Heart Trouble
Asthma
Diabetes
Hernia
Convulsions or Seizures
If answered yes above, please explain and give date:
Yes
Operation (Serious)
Illness (Serious)
Ear Trouble
Allergies
High Blood Pressure
Wear Glasses/Contacts
No