Sports/Activity Physical Form

Nassau Community College - Student Health Office
One Education Drive, Garden City, N.Y. 11530
516-572-7123 Fax: 516-572-9637
- Need Original form, No Copies, No Faxes.
Physical exam to be done within 90 days of
start of school
Telephone
(If under 18 years old, Parent/Guardian)
Parent/Guardian - If student is under 18 years old, submit notarized “Consent for Students Under 18 Years Old Form.”
Download from webpage: http://www.ncc.edu/campusservices/health_services/default.shtml
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*THIS STUDENT ATHLETE’S HISTORY FORM HAS BEEN REVIEWED*
Signature of Healthcare Provider
Healthcare Providers Stamp Here:
License Number#