College Intramural Sports Pre-Participation Clearance Form
Participant Information
Full Name
Date of Birth
Age
College / Department
Student ID
Address
Phone
Email
Emergency Contact
Contact Name
Relationship
Phone
Medical History
Asthma
Diabetes
Heart Conditions
Allergies
Recent Fractures/Injuries
Currently Taking Medication
Other Medical Conditions / Details
Additional Information
Please list any additional information relevant to your participation:
Clearance & Acknowledgement
I certify that the information provided is true and complete to the best of my knowledge.
I understand the risks associated with sports participation and agree to follow all safety guidelines.
Participant Signature
Date
Physician / Nurse Clearance (if required)
Date