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NJCAA PHYSICAL EXAMINATION FORM Each student participating in intercollegiate athletic activities sponsored by the NJCAA is required pass a complete physical examination be certified as physically fit to participate in practice and play and to keep the results on file with his college. Name of Student Name of College I have examined the student named above and indicate the results as follows Heart Blood Pressure Lungs Hernia Orthopedic Defects A. Feet B. Spine Urine A. Albumen B. Sugar Height Age I have found no reason which would make it medically inadvisable for this student to compete in any intercollegiate athletic activities EXCEPT those checked below check any activities in which the student may NOT compete. Football Basketball Wrestling Volleyball Signed Examining Physician Date of Examination Remarks To Itasca Community College Athletes From 218-327-4280 Re Athletic Insurance This memo is to notify Itasca Community College athletes that Itasca Community College does not provide insurance coverage for students participating in intercollegiate athletics. Therefore students competing in campus intercollegiate programs are required to make provisions for coverage before participating. No athlete will be permitted to participate without intercollegiate athletic insurance coverage. In checking insurance coverage for students it has been our experience that the student who can obtain his/her insurance under their parents policy will receive the best coverage for the premium paid* If this is not possible insurance information can be obtained in the College Center Building Room 105. NOTE All athletes must complete the form below and return it to their coach prior to participation in an intercollegiate program at Itasca Community College. You will not be able to participate until this from is completed in full Your Name Address City State Zip Phone Name of Policy Owner if different SSN/ Date of Birth of Policy Owner Name of Company Policy Number Group Number Date Student Signature. Name of Student Name of College I have examined the student named above and indicate the results as follows Heart Blood Pressure Lungs Hernia Orthopedic Defects A. Feet B. Spine Urine A. Albumen B. Sugar Height Age I have found no reason which would make it medically inadvisable for this student to compete in any intercollegiate athletic activities EXCEPT those checked below check any activities in which the student may NOT compete. Feet B. Spine Urine A. Albumen B. Sugar Height Age I have found no reason which would make it medically inadvisable for this student to compete in any intercollegiate athletic activities EXCEPT those checked below check any activities in which the student may NOT compete. Football Basketball Wrestling Volleyball Signed Examining Physician Date of Examination Remarks To Itasca Community College Athletes From 218-327-4280 Re Athletic Insurance This memo is to notify Itasca Community College athletes that Itasca Community College does not provide insurance coverage for students participating in intercollegiate athletics.

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