| Cobber Athletic Home | Emergency/Insurance Form |

Concordia College Returning Athlete Update
Please print form, fill out completely and return to:
Stephanie Brandt - Athletic Trainer
Concordia College
901 South 8th Street
Moorhead, MN 56562

Athlete Information

Name: Gender:
Date of Birth:
Class: Social Security Number:
Sports Playing:

Current Medical Conditions


Any series illnesses in the last 12 months:
Current Medications/Supplements:
Known Allergies:

 
 
 
Orthopedic History
Please list injuries below that were sustained in the last 12 months:
Head Injuries:
Neck:
Back Injuries:
Shoulder Injuries:
Humeral/Ulnar/Radial Injuries:
Elbow Injuries
Hand/Wrist/Finger Injuries:
Pelvis/Hip Injuries
Thigh Injuries
Knee Injuries
Lower Leg Injuries
Ankle Injuries
Foot/Toe Injuries

 
The above statements are true to the best of my knowledge.  This athlete gives consent for the team physician, consulting physician,   
Concordia Student Health Personnel and/or appropriate member of the sports medicine staff of Concordia College to examine records, or be in consultation concerning examination or treatment of the athlete for the express prupose of evaluating the medical and/or physical fitness for participation in, or continued participation in any athletic program at Concordia College.  The athlete/parent also gives permission for acceptable diagnostic, therapeutic and emergency operative procedures to be carried out in the treatment of illness and injury sustained while a member of a Concordia College Athletic Teams.
Signed                        Date