department of athletics policies & procedures - UNC Wilmington ...

_____ Approved for intercollegiate athletics at UNCW once the following recommendations have been
completed (explain):
□ Orthopedic evaluation □ Parent/guardian signature page 3 □ Medical records review from
□ Cardiology evaluation: □ Other:
_____ Not approved for intercollegiate athletics at UNCW.
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Medical Director’s Signature
Date
Follow-up completed ______/_____/________ ___________ Provider initials
UNCW STUDENT-ATHLETE
INSURANCE INFORMATION
**Please complete both sides of this form and attach a front and back copy of all insurance cards (primary,
secondary, dental, vision, etc.). If you do not have an insurance policy you still need to fill out the following
information and indicate “NO INSURANCE” on the Insurance Company line. If more than one parent/guardian is on
the same insurance plan, please fill out the demographic information for each parent/guardian separately. **
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