Dear MVCC Student Athlete:
In order to participate in Intercollegiate Athletics at Moraine Valley Community College you
must provide the following:
___ Official Transcript from High School Attended
___ Official Transcripts from Any Other Colleges
___ *Parent Insurance Information Form - This form is available on MVCC’s website.
___ *1st Agency Health Information Form - This form is available on MVCC’s website.
___*Student Waiver of Liability Form - This form is available on MVCC’s website.
___ *Physical Form- Dated within last year - This form is available on MVCC’s website.
___ *Student Athlete Health Screening Form - This form is available on MVCC’s website.
Complete the information packet and return it to the Athletic Office located in our new
Health Fitness & Recreation Building Room H120, no later than five days prior to
tryouts.
All information can be obtained in the following 3 ways:

Visit the MVCC website and download the necessary forms @
http://www.morainevalley.edu/Athletics/enrollment_forms.htm

Stop by the Athletic Office and pick up the information packet.

Call the Athletic Department at (708) 974-5727 for additional information.
We look forward to having you as a student and athlete at Moraine Valley Community
College. We are sure your athletic experience will be successful.
Sincerely,
William G. Finn
Athletic Director
Moraine Valley Community College
*These forms are available on MVCC’s website.
First Agency, Inc.
5071 West H Avenue
Kalamazoo, MI 49009-8501
PARENT/GUARDIAN/STUDENT INFORMATION FORM
Name of College/University
Moraine Valley Community College
RETURN FORM WHEN COMPLETE TO
This form is to be completed by the
Parents, Guardians or Student
Attention
Bill Finn, Athletic Director
Address
9000 College Parkway
City
State
Palos Hills
Zip
IL
60465
Note: Complete all blanks on this form. Failure to complete all blanks will result in claims processing delays.
If information is not applicable, indicate the reason it is not (e.g., deceased, divorced, unknown).
Name of Athlete
Sport
Cell Phone
Date of Birth
Home Phone
Address
City
State
FATHER/GUARDIAN INFORMATION
Zip
MOTHER/GUARDIAN INFORMATION
Father's Name
Mother's Name
Date of Birth
Date of Birth
Address
Address
Employer
Employer
Address
Address
Telephone
(
)
Telephone
(
Medical Insurance
Company or Plan
Medical Insurance
Company or Plan
Address
Address
Policy Number
Policy Number
Telephone
(
Telephone
)
(
)
)
Is this plan an HMO or PPO?
Yes
No
Is this plan an HMO or PPO?
Yes
No
Is pre-authorization required to obtain treatment?
Yes
No
Is pre-authorization required to obtain treatment?
Yes
No
Is a second opinion required before surgery?
Yes
No
Is a second opinion required before surgery?
Yes
No
First Agency, Inc.
5071 West H Avenue
Kalamazoo, MI 49009-8501
AUTHORIZATION - To Permit Use and Disclosure of Health Information
This Authorization was prepared by First Agency, Inc. for purposes of obtaining information necessary to
process a claim for benefits.
Upon presentation of the original or a photocopy of this signed Authorization, I authorize, without restriction
(except psychotherapy notes), any licensed physician, medical professional, hospital or other medical-care
institution, insurance support organization, pharmacy, governmental agency, insurance company, group
policyholder, employer or benefit plan administrator to provide First Agency, Inc. or an agent, attorney,
consumer reporting agency or independent administrator, acting on its behalf, all information concerning
advice, care or treatment provided the patient, employee or deceased named below, including all information
relating to, mental illness, use of drugs or use of alcohol. This Authorization also includes information provided
to our health division for underwriting or claim servicing and information provided to any affiliated insurance
company on previous applications. If this Authorization is for someone other than myself, that individual has
given me the authority to act on his/her behalf as explained below.
I understand that I have the right to revoke this Authorization, in writing, at any time by sending written
notification to my agent or to us at the above address. I understand that a revocation will not be effective to the
extent we have relied on the use or disclosure of the protected health information or if my Authorization was
obtained as a condition to determine my eligibility for benefits. Revocation requests must be sent in writing to
the attention of the Claims Supervisor.
I understand that First Agency, Inc. may condition payment of a claim upon my signing this authorization, if the
disclosure of information is necessary to determine the level or validity of the claim payment. I also
understand, once information is disclosed to us pursuant to this Authorization, the information will remain
protected by First Agency, Inc. in accordance with federal or state law.
I understand that I or my authorized representative is entitled to receive a copy of this authorization upon
request.
This Authorization is valid from the date signed for the duration of the claim.
Name of Claimant (please print)
Signature of Claimant (if claimant is 18 or older)
Name of Authorized Representative, or Next of Kin (please print)
Date
Signature of Authorized Representative of Next of Kin
Date
Relationship of Authorized Representative or Next of Kin to Claimant
Pre‐participation Physical Evaluation PHYSICAL EXAMINATION Name __________________________________________________Date of birth ____________ Height _________ Weight ___________ %Body fat (optional) _________ Blood Pressure ___________ Normal Medical Appearance Eyes/ears/nose/throat Lymph nodes Heart Pulses Lungs Abdomen Genitalia (males only) Skin Musculoskeletal Neck Back Shoulder/arm Elbow/forearm Wrist/hand Hip/thigh Knee Leg/ankle Foot *Station‐based examination only Abnormal findings Initials Clearance Cleared Cleared after completing evaluation/rehabilitation for: ____________________________________ _____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_________________________________ Not cleared for: _____________________________ Reason: _________________________________________________ Recommendations: _____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
________________________________________________________________________ Name of physician (print/type) _________________________________________________________________ Date: _____________________ Address _________________________________________________________________________________ Phone: ______________________ Signature of physician _______________________________________________________________________________. M.D. or D.O. ATHLETIC PREPARTICIPATION INFORMATION
STUDENT INFORMATION
Name
Sport _________________
Birthdate ________________________________
Home Address
City/State/Zip ____________________________________________________________________
Home Phone
Cell Phone
Personal E-mail: _______________________________________________________
PARENT OR GUARDIAN ADDRESS IF OTHER THAN ABOVE
Name
Address
City/State/Zip
Home Phone
Cell Phone
EDUCATIONAL HISTORY
Semester(s) out of High School
High School attended____________________________________________
Previous College(s) attended
Did you compete in a sport at another college?
If so, what sport(s)
Yes /
Graduation Date ________
Dates: from
to _______
Dates: from
to _______
Dates: from
to _______
No
Years:
I certify that I have not attended any previous college other than Moraine Valley Community College. I fully
realize that if I supply false information, my eligibility and scholarship chances at a four year institution will be
jeopardized. ________________________ (initial)
HISTORY (cont’d)
If you were not enrolled in college after high school graduation, please let us know what you
were doing i.e., working, unemployed, internship, etc.
Fall _____________________________________
Spring _______________________________
Fall _____________________________________
Spring _______________________________
YOU MUST SUBMIT TO THE MVCC ATHLETIC DEPT. OFFICIAL TRANSCRIPTS FROM
ANY COLLEGE OR UNIVERSITY ATTENDED TO THE MVCC ATHLETIC DEPT.
STUDENT SIGNATURE
I give my permission for Moraine Valley Community College to release my academic transcripts to other
colleges, universities or other institutions.
________________________________________
Student Signature
SECOND YEAR ELIGIBILITY
I understand that to be eligible to compete in a second season of any sport I must have completed at least 24
credits with passing grades, and obtained a 2.0 GPA or higher.
Student Signature
Date
MORAINE VALLEY COMMUNITY COLLEGE
PRE‐PARTICIPATION PHYSICAL EVALUATION Date:___________________
NAME
DOB / / AGE
SEX
YEAR IN SCHOOL
SPORT(S)
ADDRESS CITY/STATE ZIP
HOME PHONE #
CELL #
Emergency Contact: NAME RELATIONSHIP
HOME PHONE #
WORK #
Circle questions you don’t know the answers to. Explain "Yes" answers below.
Yes No
1. Have you had a medical illness or injury since your last checkup or sports physical?
2. Have you ever been hospitalized overnight?
Have you ever had surgery?
3. Are you currently taking any prescription or nonprescription (over-the-counter)
medications or pills or using an inhaler?
CELL #
Yes No Have you ever had a stinger, burner or pinched nerve?
8. Have you ever become ill from exercising in the heat?
9. Do you cough, wheeze or have trouble breathing during or after activit
Do you have asthma?
Do you have seasonal allergies that require medical treatment?
Have you ever taken any supplements or vitamins to help you gain or lose weight or
improve your performance?
4.Do you have any allergies (for example: to pollen, medicine, food, or stinging insects)?
Have you ever had a rash or hives develop during or after exercise?
5. 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?
10. Do you use any special protective or corrective equipment or
devices that aren't usually used for your sport or position (for example; knee
brace, special neck roll, foot orthotics, retainer on your teeth or hearing aid)?
11. Have you had any problems with your eyes or vision?
12. Have you ever had a sprain, strain or swelling after injury?
Have you broken or fractured any bones or dislocated any joints?
Have you had any other problems with pain or swelling in
muscles,tendons, bones or joints?
Do you get tired more quickly than your friends do during exercise?
Have you ever had racing of your heart or skipped heartbeats?
Have you had high blood pressure or high cholesterol?
Have you ever been told you have a heart murmur?
If yes, check appropriate box and explain below Head
Elbow
Neck
Forearm
Back
Wrist
Chest
Hand
Shoulder
Finger
Upper Arm
Hip
Thigh
Knee
Shin/Calf
Ankle
Foot
Has any family member/relative died of heart problems or sudden death before age 50?
13. Do you want to weigh more or less than you do now?
Have you had a severe viral infection (for example myocarditis or mononucleosis)
within the past month?
Has a physician ever denied/restricted your participation in sports for any heart problems?
Do you lose weight regularly to meet weight requirements for your sport?
14. Do you feel stressed out?
6. Do you have any current skin problems (for example itching, rashes, acne, warts,
fungus or blisters)?
7. Have you ever had a head injury or concussion?
Have you ever been knocked out, become unconscious or lost your memory?
Have you ever had a seizure?
Do you have frequent or severe headaches?
Have you ever had numbness or tingling in your arms, hands, legs or feet?
Explain "YES" answers here:
(continue on back.)
I hearby state that, to the best of my knowledge, my answers to the above questions are complete and correct. Furthermore, I consent to the performance of a sports physical exam,
and I hereby authorize the Athletic Director, school nurse, or their designated agents to access and utilize my performance complete preparticipation physical evaluation.
Athlete signature: _______________________________________ Parent/Guardian signature:__________________________________ Date: _____________
FIGURE 1. Preparticipation Physical Evaluation (PPE) form can be copied and used for each examination of student athletes. Using this form can help ensure that examining physicians consider the components of the cardiac evaluation recommended by the PPE Task Force. Adapted with permission from Smith DM. American Academy of Family Physicians. Preparticipation Physical Evaluation Task Force. Preparticipation physical evaluation. 2d ed. Minneapolis: Physician Sportsmedicine. 1997.
MORAINE VALLEY COMMUNITY COLLEGE
FAMILY HISTORY
Yes (Check appropriate Yes or No answers.) PLEASE ANSWER ALL QUESTIONS.
No Yes No Yes No
Asthma, Hives, Hayfever Migraine Heart Attack
Arthritis
Sickle Cell/Anemia
Strokes Seizures/Convulsions
High Blood Pressure Epilepsy Diabetes Knee Problems Explain "Yes" Answers PERSONAL MEDICAL HISTORY (Check appropriate Yes or No answers.) Are you currently taking medication ( please circle) YES NO Explain if YES Allergies? Bee Sting Adhesive Tape Tetanus
Yes No Yes No Penicillin Morphine Mycins
Yes
No Codeine Aspirin Any other allergies? Do you wear? (Please circle and explain.)
Eyeglasses Contact Lenses Dentures Dental Braces Bridgework False Eye Explain
SYSTEMS HISTORY (Check appropriate Yes or No answers.) PLEASE ANSWER ALL QUESTIONS. Irregular Pulse Mononucleosis
Menstrual Disorder Enlarged Spleen Tuberculosis Yes No Yes No Jaundice Enlarged Liver One Testicle Thyroid Disease One Working Ovary Yes No Heart Murmurs Hernia Ulcers Heat Illness Hospitalized One Kidney Explain "Yes" answers INJURY HISTORY (Check appropriate Yes or No answers.) Yes Pinched Nerve Skull Fracture Concussion Back Injury No Yes No Separated Shoulder R/L
Foot Injury R/L
Head Injury Neck Injury Yes No Knee Injury R/L
Ankle Injury R/L
Hand Injury R/L
Broken Bone Explain "Yes" Answers ATHLETE'S SIGNATURE DATE STUDENT/PARTICIPANT
WAIVER OF LIABILITY/HOLD HARMLESS AGREEMENT
&
STUDENT OFF-CAMPUS FIELD TRIP AGREEMENT FORM
This event offers a unique opportunity to gain field experience for an extended period of time. The program relies on the cooperation and good will of various private businesses, individuals, organizations and government entities. Because of our obligations to those persons and agencies and because we understandably cannot assume responsibility for the carious persons and agencies, which are in different ways connected with our programs, we ask that you adhere to the following terms and conditions of participation. Your dated signature indicates that you understand and agree to those terms and conditions. Student Name (Please Print) ____________________________________________ Age _______ Address _______________________________________ City __________________ Zip_______ Home Phone ( )_______________________ Trip to INTERCOLLEGIATE SPORTS Date of Trips AUGUST 1, 2015 TO JUNE 30, 2016 Emergency Contact – Name _______________________________________________________ Contact Number (s) Home ( )______________________ Cell ( )____________________ ** I have read the terms of this hold agreement and I understand and agree to the terms/conditions of this agreement.**
______________________________________ _____________________________________________ Name (Please Print) Signature of Participant or Parent (If a minor) ____________ Date In order to safeguard my physical health and safety and that of my fellow students, and to protect the good name and reputation of MORAINE VALLEY COMMUNITY COLLEGE while on any field trip, I agree to: Observe all public laws and ordinances, including traffic laws as well as the usages and customs of good citizenship, decorum, and courtesy while observing all rules of the host institution or agency that apply to visitor or the general public. The Student Life Office or the Academic Dean’s office at Moraine Valley Community College reserves the right to disallow, discontinue and cancel any participant’s trip with reasonable cause. Students attending off‐campus trips must attend and be on time for all aspects of the program (workshops, retreats, meetings, etc). In addition, it is understood that I am totally responsible for my conduct on the trip and in no way is the college or any college personnel liable for the effects of my conduct on the trip. I HAVE READ AND UNDERSTAND THE RULES OF THIS FORM, AND I AGREE TO ABIDE BY THEM. (If student is under 18 years of age, parental approval is necessary). Date:___________________ Student signature (parent if minor)___________________________________