MEDICAL CLEARANCE QUESTIONNAIRE

Individuals interested in trying out for an RDC Team must complete the medical clearance questionnaire prior to contacting our coaching staff.

The personal information that you provide on this form is being collected under the authority of the Post-Secondary Learning Act and the Freedom of Information and Protection of Privacy Act of Alberta. The information will be retained by the department in accordance with approved Information Management guidelines and/or may be stored on a third party system and will be protected in compliance with the provisions of the Freedom of Information and Protection of Privacy Act of Alberta. If you have any questions about the collection and use of this personal information, please contact the Athletics Director, Red Deer College, 100 College Blvd, Box 5005, Red Deer, Alberta, T4N 5H5. Telephone: 403.357.3669.

PERSONAL INFORMATION

Email address *

Last name *

First name *

1. Sport you are interested in? *

2. Date of Birth (MM-DD-YYYY) *

3. Gender *

MEDICAL INFORMATION

Please select the appropriate response. You MUST provide details below if you answer “Yes” to any of the questions

1. Do you have a history of concussions? *

1a) If yes, please provide additional information about your concussion(s)

2. Do you or have you ever experienced fainting episodes during exercise? *

2a) If yes, please provide additional information about your fainting episode(s)

3. Do you have epilepsy? *

3a) If yes, please provide additional information about your epilepsy.

4. Do you wear glasses? *

4a) If yes, are the lenses in your glasses shatterproof?

5. Do you wear contact lenses? *

6. Do you wear dental appliance? *

6a) If yes, what type of dental appliance?

7. Do you have a hearing problem? *

7a) If yes, please provide additional information about your hearing problem.

8. Do you have asthma? *

8a) If yes, please provide additional information about your asthma.

9. Do you have trouble breathing during exercise? *

9a) If yes, please provide additional information about your trouble breathing during exercise.

10. Do you have a heart condition? *

10a) If yes, please provide additional information about your heart condition.

11. Are you diabetic? *

12. Are you currently taking medication? *

12a) If yes, what medication(s)?

13. Do you have any allergies? *

13a) If yes, what allergies?

14. Do you wear a medical information bracelet or necklace? *

14a) If yes, what health problem(s)?

15. Do you have any health problem(s) that would interfere with your participation on an RDC Team? *

15a) If yes, please provide additional information regarding your health problem.

16. Are you presently injured? *

16a) If yes, what is the nature of your injury?

17. Have you ever been diagnosed with a positive COVID-19 test? *

17a) If yes to 17, did you require inpatient treatment (treatment from a doctor and/or at a hospital)? *

18. Please provide any additional information regarding any medical condition or injury not covered above.

EMERGENCY CONTACT INFORMATION

Name (First and Last) *

Relationship to you *

Contact Number (xxx) xxx-xxxx *

AGREEMENT

I agree to voluntarily tryout for an RDC athletics team. I understand that exercise carries risk and that I may experience muscle fatigue, shortness of breath, lightheadedness or symptoms of cardiovascular distress. I realize that I may voluntarily discontinue exercise at any time. The program supervisor also has the right to discontinue my participation at his/her discretion for any cause. I acknowledge that it is my responsibility to inform the supervisor of any symptoms of discomfort or pain that I may feel.

In consideration for my being allowed to tryout for an RDC Athletics team I waive all rights to sue or otherwise claim against Red Deer College, its employees or volunteers with respect to any and all losses which I may suffer as a result of injuries sustained while participating in the tryout activities.

I acknowledge that the information provided is true and I understand that failure to disclose may result in the loss of the opportunity to tryout for an RDC Athletic team. I consent to the collection, use, storage and disclosure of my personal information in the manner stated above.

AGREE *

By submitting this form you agree to the above.

* required field

Medical Intake for Tryout Form

MEDICAL CLEARANCE QUESTIONNAIRE

PERSONAL INFORMATION

MEDICAL INFORMATION

EMERGENCY CONTACT INFORMATION

AGREEMENT