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.

NWAC Regulations state: "After July 1st and prior to the first practice for participation in intercollegiate athletics, a student shall undergo a thorough 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 to perform physical examinations in the State of Washington include M.D., Doctor of Osteopathy (D.O.), Certified Registered Nurse (C.R.N.), Naturopath (N.D) and Physician's Assistant (P.A.). The physical examination shall be valid for twenty-four (24) consecutive months to the date unless otherwise limited by the physician indicating the physical is only good for less than twenty-four (24) consecutive months.

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.

*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.

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.