1-2048 Athlete Packet



Chemeketa

Community College

Athletic Sports Packet

For All Student-Athletes

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Sport Programs

Baseball Men

Basketball Men & Women

Soccer Men & Women

Softball Women

Volleyball Women

Sports Programs

Athletic Office: Bldg. 7-103 Phone # (503) 399-5081

Fax # (503) 399-5496

Athletic Director: Cassie Belmodis Phone # (503) 399-5159

Fall

Men’s Soccer

Head Coach: Marty Limbird (503) 399-5030

Women’s Soccer

Head Coach: Megan Moore (503) 312-8941

Volleyball

Head Coach: Traci Stephenson (503) 807-7177

Winter

Women’s Basketball

Head Coach: Jesse Ailstock (503) 877-7227

Men’s Basketball

Head Coach: David Abderhalden (503) 399-2554

Spring

Men’s Baseball

Head Coach: Nathan Pratt (503) 399-7953

Women’s Softball

Head Coach: Alisha Bowen (503) 917-1330

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Dear Parents:

Thanks for becoming a part of the Chemeketa athletic family.

We urge you to read the material in this packet so you may be aware of Chemeketa Community College’s Medical Coverage as it applies to your student/athlete.

We need you and your athlete to fill out all the information in this packet and return it to the appropriate coach before the first practice date.

Thanks for being a part of the CCC athletic team.

Sincerely,

Cassie Belmodis

Athletic Director

JN

Welcome to the Chemeketa Community College

Athletic Program

This sports packet of materials contains a number of forms that must be completed in order to participate in the Chemeketa athletic program. All forms must be completed and returned to your coach on or before the first day of practice.

The first part of the packet contains intercollegiate athletic accident insurance information. Please keep all this information for future reference.

All athletes must complete the following forms:

1. Intercollegiate Athletic Coverage (requires signatures)

2. Emergency Information Sheet

3. Athlete Primary Insurance Information Form

4. Measles Immunization Requirement

5. NWAACC Athletic Questionnaire/Recruiting Disclaimer

6. Student/Athlete Physical Form – Personal

7. Physical Examination – by Physician

All student-athletes must have a physical every two years and the form must be turned in before the first day of practice for your sport.

Transfer Students only must complete the NWAACC Tracer Report Form. (It can be faxed from CCC Athletic office to previous colleges).

An official transcript from previous colleges must be mailed to Chemeketa Admission's office.

Every student has the responsibility to update all forms as necessary.

CHEMEKETA

COMMUNITY COLLEGE

M E M O

TO: STUDENT ATHLETES AND THEIR PARENTS

RE: ATHLETIC TEAM ACCIDENT GROUP COVERAGE

The college provides accident insurance for intercollegiate athletes. This coverage is only for accidental injuries sustained during team practice, play in a regularly scheduled game, and group travel to and from games or practices.

The plan does not cover medical expenses for sickness or accidental injuries sustained outside the student’s performance as a member of an eligible Chemeketa athletic team.

Benefits are payable after satisfaction of a $250 deductible per injury and after other available group insurance benefits have been paid. Claims must be submitted to other group plans for reimbursement before they are submitted to this plan for consideration. If no other insurance exists, claims should be sent directly to this plan.

Benefits in the Basic Plan are based on reasonable and customary fees charged by providers in the Salem, Eugene, and Portland areas. Since some medical expenses may not be reimbursed by this plan, parents are urged to keep eligible dependent children covered on their employer’s group medical, dental, or vision plans as long as possible.

Plan brochures and claim forms may be obtained from the team coach or the Physical Education Department in Building 7. Inquiries regarding coverage or claims should be directed to the claims administrator as listed below:

SUMMIT AMERICA INSURANCE SERVICES, L.C.

7400 College Boulevard, Suite 100

Overland Park, KS 66210

Phone: 877-246-6997

Fax: 913-327-7520

Chemeketa Community College

Intercollegiate Athletic Coverage

TO: Chemeketa Athletes

RE: Athletic Injuries

The college provides accident insurance for students participating in intercollegiate athletic programs. This is SECONDARY coverage for any athlete who is covered by another plan. The policy has a $250 deductible per injury.

All Athletic injuries, whether occurring on or off campus, must be reported immediately to your coach.

1. According to Chemeketa Board of Education policy, all athletes are covered by a $250 deductible secondary accident insurance plan for injuries that occur during a Chemeketa sponsored athletic event.

2. All athletes will IMMEDIATELY report injuries to their coach. Athletes will report to their coach at least weekly while undergoing treatment and until a written release from the doctor is received.

3. Athletes will complete the insurance claim form and provide required information about primary insurance coverage which is provided through parents’ employment.

4. Insurance forms are available from the coach or the Athletic Department.

5. Athletes will be responsible for non-insured medical expenses.

6. Athletes will be responsible for sending the completed claim form, medical bills and primary Insurance company payment statements to the claims administrator, Summit America Insurance Services, 7400 College Blvd., Suite 100, Overland Park, KS 66210, Phone (toll-free) 1-877-246-6997. Medical bills not submitted to the claims administrator will not be paid by the college.

7. Athletes will be responsible for billing their primary insurance carrier for maximum benefits before the college insurance plan makes any payments.

I have read and understand the above insurance policides/procedures of the Chemeketa Community College intercollegiate athletic program.

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Student Signature Date Parent Signature Date

Student Printed Name Parent Printed Name

4000 Lancaster Drive NE / PO Box 14007 / Salem, Oregon 97309-7070 / PHONE: 503-399-5081

Date ____________________ Sport _______________________

Chemeketa Athletic Department

Emergency Information

Name: Birth Date: Age:

Parents or Guardian Name:

Address:

Home Phone: Work Phone:

In case of an emergency, if parent/guardian cannot be contacted:

Notify: at:

Name Telephone Number

Are you allergic to any medications? Yes_____ No_____

If yes, what?

Are you diabetic? Yes_____ No_____

Name of Insurance: Insurance Group Number: _

Parent/Guardian Medical Release

If, I (parent/guardian) _________________________ cannot be contacted in the event of an emergency,

I give permission for __________________________ (coach) to make medical decisions for my child.

Athlete Primary Insurance

Information Form

Athlete Information:

|Name: | |

|Social Security Number: | |

|Campus Address: | |

|Telephone: | |

| | |

|Family Information: | |

|Father's Name: | |

|Social Security Number: | |

|Occupation: | |

|Address: | |

|Home Address: | |

|Telephone: | |

|Employment: | |

|Employer Address: | |

|Employer Telephone: | |

|Insurance Carrier: | |

|Carrier Address: | |

|Insurance Group Number: | |

| | |

|Mother's Name: | |

|Social Security Number: | |

|Occupation: | |

|Address: | |

|Telephone: | |

|Employment: | |

|Employer Address: | |

|Employer Telephone: | |

|Insurance Carrier: | |

|Carrier Address: | |

|Insurance Group Number: | |

|Insurance athlete is covered under: | |

New and Transfer Chemeketa

Student Athletes Community College

Certificate of Immunization Status

Document of Verifying Measles Protection

Instructions:

Students who are born on or after January 1, 1957, involved in clinical experiences in nursing or allied health programs, practicum experiences in education or child care programs, certain work experience programs, and membership on intercollegiate sports teams must have two doses of measles vaccine prior to participation. Proof of immunization must be provided or a properly documented religious or medical exemption signed. For information about what constitutes proof of immunization, consult your advisor.

The Student

Last Name First M.I.

Street Address City

County Zip Telephone

S.S.# Sex Birth Date (mo/day/yr)

Section A Section B

Vaccine History Religious Exemption

I have read and understand the information

Vaccine Dose Mo. Day Yr. Initial Date below about the risks of nonimmunization.

I am an adherent to a religion the teachings

Measles 1 of which are opposed to immunization, and

I request that I therefore be exempted from

2 immunization requirements.

______ __

Health Care Professional Verification Signature Date Signature Date

Section C

Medical Exemption

I certify that the above-named student should be exempted from the requirements for the measles vaccine.

Based on:

n History of disease (mo/yr)

n The following reason which constitutes a medical contraindication in accordance with the Advisory Committee on immunization Practices of the U.S. Public Health Service for the vaccine(s) indicated:

Health Care Professional (Please print) Phone

Signature of Health Care Professional (MD ND DO NP) Date

Risks of Nonimmunization

Immunization is a safe and effective way to protect against vaccine-preventable diseases that can hurt, cripple, and even kill.

Measles is a serious disease characterized by rash and moderate to high fever. It can lead to pneumonia, serious ear infections, deafness, convulsions, inflammation of the brain, and even death. Severe complications develop in one out of each thousand cases. One in ten of such complicated cases will result in death. Measles can spread rapidly among nonimmunized people in a group situation such as a school day care center practicum site.

Students with religious or medical exemption(s) (except a verified history of disease) are not protected against the disease, which means that they are at risk of getting the disease. In the event of an outbreak, students with a religious or medical exemption for the particular disease may be excluded from their student placements in health care, education, or childcare settings or from their participation in sports competition.

Immunizations are vital to your good health. When immunization levels go down, disease levels go up.

Chemeketa Community College

P.O. Box 14007

Salem, OR 97309

Student/Athlete Personal Medical History

PLEASE CAREFULLY AND COMPLETELY READ THE FOLLOWING INFORMATION

Completion of this medical history and examination form is mandatory for participation in the sports programs of this college. Please make sure that all statements regarding your personal information and medical history is complete and accurate.

NWAACC Regulations state: After July 1st and prior to the first practice of each year of participation in intercollegiate athletics at a member college, a student-athlete shall undergo a medical examination and be approved for intercollegiate athletic competition by a medical authority licensed to perform a physical examination by the laws applicable in the state where the exam is conducted. Those licensed and approved to perform physical examinations include Medical Doctors (M.D.), Doctors of Osteopathy (D.O.), Certified Registered Nurses (C.R.N.), Naturopaths (N.D.) and Physician's Assistants (P.A.).

This form is to be completed and signed by the student or, if the student is under the age of 18, by the student's parent or guardian. Any Information withheld or falsified may affect the student's status on the athletic team and/or the student's scholarship funding. The college reserves the right, with the student's authorization, to request past medical records, charts and diagnoses regarding injuries, medical history or physical condition, and may request additional medical examinations or tests if indicated.

NWAACC (2004) Page 1 of 6

YOUR LAST PHYSICAL EXAMINATION

Date ___________________ Doctor's name ___________________________ City, State ____________

Please list any abnormalities found on any past physical examinations ___________________________________________

____________________________________________________________________________________________________

IMMUNIZATION RECORD

|Measles* |( Yes |( No |Date of last shot |__________________ |

|Mumps* |( Yes |( No |Date of last shot |__________________ |

|Rubella* |( Yes |( No |Date of last shot |__________________ |

|Polio |( Yes |( No |Date of last dose |__________________ |

|Tetanus (Td) |( Yes |( No |Date of last shot |__________________ |

*Note: These are commonly noted on immunization records as "MMR" and often given as one shot.

A second dose of measles vaccine is recommended for college entrance.

FAMILY MEDICAL HISTORY

Please check YES or NO in appropriate box.

|1. |( Yes |( No |Osteoporosis | |5. |( Yes |( No |Hemophilia |

|2. |( Yes |( No |High blood pressure | |6. |( Yes |( No |Diabetes |

|3. |( Yes |( No |Neuromuscular disease | |7. |( Yes |( No |Anemia |

|4. |( Yes |( No |Sudden death from heart disease or | |8. |( Yes |( No |Cancer |

| | | |stroke | | | | | |

If living, please check box to signify family member's general health. If deceased, please state age and cause of death, if known.

| | | | | | |Age at Death Cause of Death |

|Father |( Excellent |( Good |( Fair |( Poor |( Deceased |______________________________ |

|Mother |( Excellent |( Good |( Fair |( Poor |( Deceased |______________________________ |

|Brother #1 |( Excellent |( Good |( Fair |( Poor |( Deceased |______________________________ |

|Brother #2 |( Excellent |( Good |( Fair |( Poor |( Deceased |______________________________ |

|Sister #1 |( Excellent |( Good |( Fair |( Poor |( Deceased |______________________________ |

|Sister #2 |( Excellent |( Good |( Fair |( Poor |( Deceased |______________________________ |

MEDICAL CONDITIONS & ILLNESSES

Have you ever had or do you now have any of the following medical conditions, illnesses or diseases?

Please check YES or NO for EACH item.

| |YES |NO | |

|93. |( |( |Do you now have or have you ever had any chronic or recurrent illnesses? |

|94. |( |( |Have you ever had any illnesses lasting more than one week? |

|95. |( |( |If no to #93 or #94, do you now have or have you ever had any illnesses requiring treatment and care of a doctor? |

|96. |( |( |Do you wear eyeglasses or contact lenses? |

|97. |( |( |Do you currently wear eyeglasses or contact lenses while participating in sports? |

|98. |( |( |Do you use any dental appliances such as braces, bridges or plates? |

|99. |( |( |Any body parts or organs missing (appendix, eye, kidney, testicles)? |

|100. |( |( |Are you now or have you ever been under the treatment of a medical doctor for any injuries? |

|101. |( |( |Have you ever fainted, passed out, been dizzy, knocked out, unconscious or had a concussion? |

|102. |( |( |Have you ever had a cast, splint, cane or crutches? |

|103. |( |( |Have you ever had an X-ray of any bone or joint? |

|104. |( |( |Do you have to stop while running twice around a quarter-mile track? |

|105. |( |( |Do you have any trouble breathing, while at rest, after running one mile? |

|106. |( |( |Do you get any chest pain with exercise? |

|107. |( |( |Have you ever had any injuries or illnesses that caused you to miss a game or practice? |

|108. |( |( |Are there any reasons why you should not participate in sports? |

|109. |( |( |Have any of your close relatives, under the age of 50, died of heart problems or unexplained causes? |

|110. |( |( |Are you or any member of your family allergic to ANY medications (aspirin, penicillin, etc.)? |

|111. |( |( |Are you now taking or have you taken any medications, medicines, drugs or vitamins on a regular basis? |

|112. |( |( |Do you have any medical conditions that require special attention or treatment that the coach or athletic trainer should be aware of |

| | | |in the event of any injury or illness? |

If you have answered "Yes" to any numbered item (1-112), please explain the situation or circumstances, including names of treating physicians and dates in the space provided. Identify each response by the number of the item in the left margin.

|Item No. |Physician, City, State |Approx. Date |Explanation, including any surgeries you have had |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

Student Name ________________________________________________________ Page 3 of 6

(Last) (First) (Mid. Initial)

Please list all previous fractures, concussions or other head injuries:

|Item No. |Physician, City, State |Approx. Date |Injury |

| | | | |

| | | | |

| | | | |

| | | | |

Please list all hospitalizations:

|Item No. |Physician, City, State |Approx. Date |Reason for hospitalization, length of stay |

| | | | |

| | | | |

| | | | |

| | | | |

Describe your current pattern of physical exercise

|Activity |Frequency |Duration |Intensity |

| | | | |

| | | | |

| | | | |

| | | | |

Describe the sickest you have ever been __________________________________________________________________________

____________________________________________________________________________________________________

Describe any weight changes over the last six months________________________________________________________________

List all medications -- prescription and/or over the counter -- drugs or vitamins that you currently take (including aspirin, birth control-pills,etc.) ___________________________________________________________________________________________________

____________________________________________________________________________________________________

Describe any allergies -- from bites, drugs, foods, pollen, etc. -- you may have, including causes and reactions ___________________

____________________________________________________________________________________________________

At what age did you have your first menstrual period? ______ How many have you had during the last 12 months? _______

Date of last period ________ Describe any menstrual irregularity or discomfort ________________________________

AGREEMENT OF UNDERSTANDING

I, the undersigned, certify that the above medical history is correct and true to the best of my knowledge, and that this student has no physical defects except as stated. This medical information is given with my permission and the medical examination is taken voluntarily. I further understand that any intentional omission of answers either verbally or in writing may result in disqualification from the community college sports program.

I authorize the release of this medical information, including the medical examination and the results of any medical tests, to the college for their use, evaluation and record keeping for this student-athlete's participation in the sports program of the college. I further authorize the release of this medical information, the medical examination and the results of any medical tests when deemed necessary by the college athletic coach, athletic trainer or other authorized college official; and I grant permission to any hospital, physician, surgeon, or other duly authorized medical personnel to release any other medical records, charts or diagnoses when deemed necessary for the treatment and care of this student-athlete in the event of injury or illness.

I further authorize and request the college's designated medical personnel to administer basic life support, advanced life support, and/or to obtain emergency medical care in the event of injury or illness at any specific emergency care facility so designated by the college physician or representative while participating in the sports program.

By my signature I verify that I have read, understand and agree to the above-stated conditions.

Student _______________________________________________________________ Date ___________________________

Parent/Guardian (If student is under 18 years of age)______________________________________________________________________

Student Name ________________________________________________________ Page 4 of 6

(Last) (First) (Mid. Initial)

PHYSICAL EXAMINATION FOR SPORTS PARTICIPATION

To be completed by Licensed Medical Provider

To the Medical Provider: Please obtain and review the student's health history, pages one through four of this form, before conducting the examination. The intent of this exam is to focus on conditions of the athlete that may endanger his/her health, aggravate pre-existing conditions or increase the risk of death from participation in competitive college sports. If your findings or observations during this exam for sports participation indicate a need for a more comprehensive medical examination, you have the option of conducting a more comprehensive exam or advising the athletic director of the college in writing of the need for same. We appreciate your assistance and cooperation in maintaining the health of our student-athletes.

Student Name ____________________________________________________________________________________

(Last) (First) (Middle Initial)

Date of Birth __________________ Male ( Female ( Height ___________ Weight ___________

Month/Day/Year

Blood pressure at rest and sitting: Left arm _________/_________ mmHG Right arm _________/_________ mmHG

Resting pulse rate: Apical __________ Radial __________

Visual acuity: Left 20/________ Right 20/________ Please check appropriate box: ( With correction ( Without correction

Please check appropriate box to indicate if Normal or Abnormal, and provide comments if abnormal.

|SYSTEM | |N |AB |COMMENTS |

|HEAD |Hair, scalp, masses, injuries | | | |

|EYES |Proptosis, conjunctivae, sclera, EOM, | | | |

| |pupillary size, reaction to light, | | | |

| |peripheral vision, fundi, gross tension to | | | |

| |palpation | | | |

|EARS |Gross hearing to speech, drums, discharges | | | |

|NOSE |Septum, mucosa, sinuses | | | |

|THROAT/MOUTH |Teeth, tongue, tonsils, infections, lesions | | | |

|NECK |Thyroid, vessels, range of motion, adenopathy, | | | |

| |masses, voice abnormalities | | | |

|THORAX/LUNGS |Shape, expansion, deformities, rhonchi, wheezes, | | | |

| |rales | | | |

|HEART |PMI, sounds, thrills, murmurs, gallops, PVCs | | | |

|LYMPHATICS |Cervical, axillary | | | |

|ABDOMEN |Organ enlargement (liver, spleen, etc.), masses, | | | |

| |tenderness, hernias, scars | | | |

|GENITALIA |Scrotum, testicles, lesions, discharge, hernias | | | |

|RECTAL (Optional) |Hemorrhoids, fissures, prostate, masses | | | |

|UPPER EXTREMITIES |Range of motion, joint stability, muscle strength, | | | |

| |limitations, effusion, ecchymoses, atrophy, | | | |

| |deformities, edema, clubbing, pulses, veins, | | | |

| |injuries | | | |

|LOWER EXTREMITIES |Range of motion, joint stability, muscle strength, | | | |

| |limitations, effusion, ecchymoses, atrophy, | | | |

| |deformities, edema, clubbing, pulses, veins, | | | |

| |injuries | | | |

|BACK |Flexion, extension, scoliosis, kyphosis, excessive | | | |

| |lordosis, injuries | | | |

|NEUROLOGICAL |Cranial nerves, reflexes, motor, gait, balance, | | | |

| |sensory | | | |

|SKIN |Texture, striae, rash, acne | | | |

|MENTAL STATUS |Affect, hostility, agitation | | | |

Page 5 of 6

LABORATORY TESTS (Optional or as indicated by examination)

Urinalysis: Sugar _________ Albumin _________ Keytones _________ Other _________________________

Hematology: Hematocrit ________________________

Summary of abnormal lab work __________________________________________________________________________________

If medical history indicates the need for any vaccinations or booster shots, please administer during the physical examination.

Orthopedic Diagnoses ________________________________________________________________________________________

____________________________________________________________________________________________________

General Medical Diagnoses ____________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

Additional findings or comments on health history/significant injuries or illnesses ___________________________________________

____________________________________________________________________________________________________

DISPOSITION (Please check one)

( Unrestricted activity in all sports

( No participation until ______________or until ____________________________________________________

(Date) (Conditions to be met)

( May participate, but with following limitations _____________________________________________________

( May not participate at all for following reasons _____________________________________________________

Medical Provider's signature _____________________________________________ Date of Exam ________________

|MEDICAL PROVIDER IDENTIFICATION (Please print. Stamp or label okay) |

| | |

|Name _________________________________________________________ |Phone (______) _____________________ |

| | |

|Address _______________________________________________________ |City _________________ Zip __________ |

Mail completed form to:

NOTE: The original of this report shall be confidentially filed and maintained in the athletic department. The information shall be readily available to health care providers in event of an emergency when intercollegiate sports are conducted, both at home and away from the college.

Student Name ________________________________________________________ Page 6 of 6

(Last) (First) (Mid. Initial

Northwest Athletic Association of Community Colleges

Athletic Questionnaire/Recruiting Disclaimer

Institution ________________________________ Sport(s) ____________________________ School Year

Name ____________________________________ SSN ______________________________ Birthdate

Home Address _______________________________________________________________ Phone

College Address (if different) _____________________________________________________ Phone

High School _________________________________________________________________ Graduation Date

Have you attended other collegiate institutions, including community colleges, since high school? Yes ___ No ___

If “Yes”, list the names of the college and dates (month/year) of enrollment

State the number of (quarter/semester) hours transferred

Are the required transcript copies from all previous colleges attended on file with the Chemeketa Admissions Office? Yes ___ No ___

Athletic Participation:

Have you participated in an intercollegiate contest or event since high school (including community college)? Yes ___ No ___

Have you participated in an intercollegiate practice since high school (including community college)? Yes ___ No ___

If “Yes”, complete the following listing of dates and any participation at all colleges you attended, including present college.

19________ to ________

19________ to ________

Are you now participating on any other team? Yes ___ No ___ If “Yes”, name the team _______________________________________

When was the last time you participated? __________________ Have you notified the team you are leaving? Yes ___ No ___

Letter of Intent:

Have you ever signed a letter of intent. Yes _____ No _____ If “Yes”, for which sport?

19________ to ________ (college)

Amateurism:

Have you ever participated or tried out for a professional team? Yes ___ No ___

Have you ever played with, received payment or signed a contract to play with a professional team? Yes ___ No ___

If “Yes”, list the sport, organization, and date signed

Scholarships and Financial Status:

Have you been awarded an athletic tuition grant-in-aid at this college during this academic year? Yes ___ No ___

Have you received any other (nonathletic) scholarship or aid from this college during this academic year? Yes ___ No ___

To the best of my knowledge, the information I have listed on this questionnaire is accurate and complete. I understand that falsification of my academic or athletic participation records will result in immediate suspension of athletic eligibility in any sport in an NWAACC member college.

(over)

Date _____________________________________ Signature______________________________________________________

NWAACC Recruiting Disclaimer

In accordance with Article VI, Section 2 (Athletic Recruiting) of the NWAACC Official Code, the following disclaimer is submitted, specifically, Article VI, Section 2 states: “Athletic recruiting will be confined to only the states of Oregon, Washington, Alaska, California, Idaho, Nevada and the province of British Columbia. Student athletes whose home residence is outside the aforementioned contiguous states must submit an NWAACC athletic questionnaire to the conference office and a written affidavit from the college in attendance indicating:

1. Reason for attendance

2. College contacts or correspondence

_____________________________________ ___________________________________

Student Signature Athletic Director

_____________________________________ _______________________ ____________

College President Coach

NWAACC Tracer Report

To: From: Chemeketa Community College Date:

Fax # (503) 399-5496

The information requested below is needed to determine a student’s athletic eligibility. We and the student would appreciate a prompt return of this form. Thank you for your assistance and cooperation.

To Be Completed by Student-Athlete:

It is my request that the below information be sent to the appropriate college officials.

Student’s signature ___________________________________________ Date ___________________________

Male/Female _______________________ ____________

Full name of student (print) Please circle Social Security Number Date of birth

From ________________ To ________________

Dates student attended your institution Sport(s) student participated in

To Be Completed By Student-Athlete’s Previous College:

1. Did this student attend your college? Yes ___ No ___ Date attended _____________ to ______________

2. Did this student participate in intercollegiate athletics at your institution? Yes ___ No ___

3. Was this student injured while participating in a scheduled game, meet or match? Yes ___ No ___

The NWAACC Athletic Code defines participation as “Participation in any contest, other than an approved scrimmage, regardless of time, shall be counted as one season of competition in that sport and the participant will have used one year of collegiate eligibility.”

If yes, what sport(s), number of contests, and year(s).

1. Sport _____________________________ Number of contests ______ Month/Year ___________________

2. Sport _____________________________ Number of contests ______ Month/Year ___________________

3. Sport _____________________________ Number of contests ______ Month/Year ___________________

Student’s last date of attendance _________________________

Do you have knowledge of any attendance by this student at another post-secondary institution? If so, please indicate the name of the institution and the date(s) of attendance.

Institution _______________________________________ Date attended ______________ - ______________

From To

Name of person completing this form (please print)

Signature ____________________________________ Title _________________________ Date ____________

Please return to: Cassie Belmodis, Athletic Director Fax # (503) 399-5496

Chemeketa Community College Phone # (503) 399-5081

PO Box 14007

Salem, OR 97309

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Student Name ____________________________________________________________________________________

(Last) (First) (Middle Initial)

Date of Birth __________________ Male ( Female ( Social Security Number ______________________

Month/Day/Year

Local Address ________________________________________________________ Phone (______)______________

(Number & Street) (City) (Zip)

Home Address ________________________________________________________ Phone (______)______________

(Number & Street) (City) (Zip)

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Parent(s) Name ____________________________________________________________________________________

(Last) (First) (Middle Initial)

Home Address ________________________________________________________ Phone (______)______________

(Number & Street) (City) (Zip)

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Are you covered by group or individual health and/or accident insurance? Yes ( No (

If yes, please provide the following information:

Insurance Co. ___________________________________________________ Policy #_________________________

Subscriber's Name ________________________________________ Subscriber's Soc.Sec. #______________________

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Name _______________________________________ Phone (______)____________ Relationship ________________

Name _______________________________________ Phone (______)____________ Relationship ________________

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Name _______________________________________________________________ Phone (_______)____________

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Please check ALL appropriate boxes for the sports in which you will be participating at this college:

|( Baseball |( Field Hockey |( Hockey |( Soccer |( Track |

|( Basketball |( Football |( Rowing |( Softball |( Volleyball |

|( Cross Country |( Golf |( Skating |( Swimming |( Wrestling |

|( Diving |( Gymnastics |( Skiing |( Tennis |( Other __________ |

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