Physical Forms:

Dear Student-Athlete and Guardian:

On behalf of the Lake-Sumter Community College Athletic Department I want to welcome you to our Athletic program.  As the Head Athletic Trainer, I am responsible for the healthcare of all the athletes.  My primary goal is to keep every athlete healthy all year long.  However, if an injury does occur during athletic participation, the athlete will receive excellent medical care while here at LSCC.  I, the Team Physician and student trainers will be available to assist an athlete in the case of an injury.

All athletes must complete several forms before they will be allowed to participate in the intercollegiate program here at LSCC.  Please make sure you read the Insurance Policy Form carefully, so you understand how the College’s Secondary Insurance Policy is handled.  Also, please complete the entire Parent Information Form, filling in all spaces.  Correct information on this form is vital to the handling of the insurance policy.  If, at any time during the year, the insurance coverage of the athlete changes please notify the Athletic Department immediately so the information can be updated.  Please make a copy of the Insurance Card and return it with this form.  The Medical History Form must be completely filled out and signed in front of a notary.  Please use the checklist to make sure you return all the needed forms, so your participation in athletics at LSCC is not delayed.  ALL FORMS MUST BE TURNED IN PRIOR TO ANY PARTICIPATION!!

1. Read and sign the Athletic Insurance Policy, as well as the Release for Treatment.
2. Completely fill out the Parent Information Form and attach a copy of the Insurance Card, returning

student-athlete’s do not have to fill out if information has not changed.

1. Complete the Medical History Form accurately, must be notarized. 
2. Physical Form complete by a qualified health care professional with signature, printed name and stamp on the form.
3. Read and Sign the Student-Athlete Authorization/Consent for Disclosure of Protected Health Information form (HIPAA).
   
4. Please have Orthopedic Evaluation Form filled out but not signed by a physician.

Physicals can be performed by any health care professional licensed to administer physical examinations; in most cases it is easiest to see your primary care Physician.  We also ask that the athletes get an EKG, ECG or a stress test in conjunction with their physicals.  THIS IS MANDATORY TO PARTICIPATE!  If you do not have a primary physician or do not have a way to get the physical performed on your own, please contact the Athletic Department or myself and we will assist you in getting the physical completed.  Please remember that the physical has to be competed and turned in PRIOR TO ANY PARTICIPATION!

Also, it is a fundamental belief of the NJCAA that athletic participation is a privilege and that those athletes who use illegal performance-enhancing and/or recreational drugs ultimately violate that privilege.  LSCC Athletic Department supports the NJCAA in this belief and will be performing random drug testing throughout the academic school year.

Thank you for your cooperation with all the paperwork.  If you have any questions regarding any of the forms, please feel free to contact me at (352) 435-6320 and/or harti@lscc.edu.

Send Forms To:
LSCC
Attn:  Jake Hart
9501 U.S. Hwy 441
Leesburg, FL 34788

• Medical History Form
• Physical Form
• Athletic Insurance Policy
• Student Information
• HIPAA Form
• Orthopedic Evaluation Form