FLEMING COLLEGE STUDENT ATHLETE APPLICATION
Campus (please circle) Student # _________________ Gender
Name
(Peterborough or Lindsay)
Sport (mandatory)
Position
Fleming Email
Alternate Email
Local Phone #
Local Address
City
(mandatory)
MALE or FEMALE
Postal Code
st
nd
College Program (mandatory)
This year will be 1 2
3rd 4th 5th year of Athletic Participation
Health Card #(mandatory)
Height
Weight
Date of Birth (d/m/y)
Please indicate all previous post-secondary institutions you have attended:
Please indicate all previous (semi) professional teams you have participated with:
Please indicate the last team you participated with, and the date of your last competition
Previous Years of Eligibility Use Please Circle One: 0
Citizenship
1
2
3
4
Hometown Address
City
Postal Code
Phone #
Please indicate below the NAME ADDRESS AND PHONE NUMBER of the person to be notified in case of EMERGENCY
Name
Phone #
Address
Relationship to you
City
Postal Code
NOTICE OF COLLECTION OF PERSONAL INFORMATION
As part of the Fleming College Athletic Program you will be required to provide personal information as part of your application. This personal information will be
used by the College to administer the Varsity Athletic program. As a member of a varsity team, you are giving permission to The College to access your academic,
personal and financial and medical records. This personal information will be shared with members of the Athletic Department, Coaching Staff, OCAA and CCAA in
the regular completion of their duties as per Policies and Procedures.
I have read the Policies and Procedures governing participation in Intercollegiate Athletics and support the program goals contained therein.
_______________________________________
Signature of Student/Athlete
Participation in Athletics and Recreation activities involves the risk of personal injury. The use of the equipment, facilities and premises of Sir Sandford Fleming
College (“the College”) by persons participating in athletics and recreation activities shall constitute acceptance of that risk regardless of the nature of the injury. The
College, its officers, employees, agents and OCAA shall not be liable for any injury, loss or damage sustained or suffered by persons participating in any athletics or
recreation activities at the College, whether caused either directly or indirectly by the negligence or fault of the College, its officers, employees, agents or otherwise.
____________________________________________
Signature
_____________________________________
Date
PHOTOGRAPH PERMISSION
Pursuant to section 39(2) of the Freedom of Information and Protection of Privacy Act,
I, _____________________________________________________ hereby consent to:
(First and Last name)
a)
the use of personal information obtained during this interview, and
b)
the use of any supplemental personal information pertaining to the initial interview which may be needed by the College at a later date; and
c)
the use of any photographs or videotape taken by College personnel or by individuals contracted by the College for such purpose.
I understand that my personal information will be used for promotional purposes which include College publications, broadcasts, website and / or use by the public
media when that media requires my information in connection with the printing / broadcasting / web posting of College-related publicity.
The legal authority for the collection of this information is the Ministry of Colleges and Universities Act. R.S.O. 1980, C.272
____________________________________________
Signature
____________________________________________
Date
Please complete other side
FLEMING COLLEGE STUDENT ATHLETE APPLICATION
Please complete the medical form. Information remains confidential and only used in medical situations in consultation with the Athletics &
Recreation Department, coaching staff and Athletic Therapist.
Name:
Sport:
Date of Birth (DD/MM/YY):
Height:
Doctor’s Name & Phone # :
OHIP #:
Do you wear EYE GLASSES or CONTACT LENSES?
At any time?
Weight:
To play sports?
Are you currently taking any medication?
Yes
No
if yes, specify:
Do you have allergies (food, drugs, etc.)?
Yes
No
if yes, specify:
Have you ever sustained a head injury?
Yes
No
if yes, specify (date/severity/symptoms):
Have you ever had a spinal injury?
Yes
No
if yes, specify:
Have you ever had a surgery/operation?
Yes
No
if yes, specify:
Do you have any medical conditions that are made worse by, or cause distress during exercise?
(e.g. asthma, chest pains, muscle cramps, etc.)
Yes
No if yes, specify:
Has a Doctor ever told you that you should not participate in sport or physical activity?
Yes
No
Do you suffer from any of the following conditions/areas:
Epilepsy
Ulcers
Migraines or headaches
Asthma
Dizzy Spells
Fainting
Diabetes
Kidney
High blood pressure
Anemia
Cancer
Blood Disorder
Mental Disorder
Hay fever or hives
Heat problems
Respiratory problems
Skin condition
Menstrual problems
Hernia
Eye or ear problems
If YES, please provide details:
Do you suffer from any OTHER CONDITIONS not mentioned above?
Please indicate if you have suffered injuries (sprains, strains, fracture, etc.) to any of the following areas:
Head
Nose
Upper back
Thumb
Teeth
Ears
Lower back
Finger
Achilles Tendon
Hip
Thigh
Sternoclavicular joint
Neck
Thorax
Ribs
Shoulder
Rotator Cuff
Knee
Lower leg
Ankle
Sternum
Acromioclavicular Joint
Elbow
Upper arm
Forearm
Wrist
Hand
Foot
Toes
Patella
Other:
If you checked any of the above, please specify below:
Date Injured (DD/MM/YY):
Area:
Did you receive treatment
(YES/NO)?
Is the injury still causing you
problems?
I (print) _________________________________ have read and answered the Sir Sandford Fleming College Varsity Athletic Medical
Information Form (see above). I certify all my answers to be true and I declare myself in good health and ready to participate in Varsity
Athletics at Sir Sandford Fleming College.
________________________________________
Signature
______________________________________
Date
Fleming College promotes the full inclusion of students with disabilities. If you require an accommodation in order to participate in varsity
programs please contact: Fred Batley Varsity Coordinator, PSWC at fred.batley@flemingcollege.ca or 705 742-1590